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what would YOU choose?

Here is a story of a choice about an abortion, a theraputic abortion, where a mother has to make a difficult choice. I have seen Family Medicine patients since 1991, so this will not identify a particular person. No HIPAA problem.

I see a new patient in clinic, a woman, who already has children. She has back pain. All is routine until she says, “Sometimes my leg goes numb from the knee down.” I stop. This is NOT normal. “Completely numb?” I say. “Not patchy?” “Yes.” “How often?” I ask. She shrugs. “Not very.” “If it happens again, call me and I want to see you right away.”

Why? This is unusual because most numbness follows dermatomes if it is from back pain. The dermatomes on the skin wrap from the back down the leg all the way to the toes. When someone describes numbness or the pain of shingles in that distribution, we know which nerve is affected. Numbness from the knee down can come from diabetes and other causes, but it is not on one side and it doesn’t come and go. So the unusual stands out for me.

“Anything else weird?”

“I had vision problems in my last pregnancy. They sent me to specialists, even a neuro opthamologist. He couldn’t find anything.”

“Ok.” I shrug. We move on.

She calls two days later. “Both legs are numb from the knee down.”

“Come in today,” I say.

Both legs ARE numb from the knee down. She also can’t lift her feet. The muscles from the knees down are weak. I get neurology on the phone. “MRI her from the top of her head to the base of her spine.” I call the hospital and set it up. That day.

She has seven brain lesions suspicious for multiple sclerosis. She did have an MRI in the previous pregnancy, which was negative. I do not remember how old the child was, 2-4 years or more when I saw mother.

I call her back in for results, we talk about specialists, and I call a neurologist in the nearest big city, three hours by car from where she lives. We start medications and my patient is scheduled.

She has multiple sclerosis. The flare improves. The visual symptoms were MS in the previous pregnancy, but it was not yet visible on brain MRI.

Then she gets pregnant again. Her symptoms immediately flare. She comes to me and I call the neurologist.

The symptoms are not a little worse. Much worse. “I suggest she terminate the pregnancy.”

My patient is horrified. Until the neurologist’s next words. “She needs to terminate if she wants to be able to walk for the children she has.”

My patient chooses an abortion, to terminate the pregnancy. Because she has a bad version of MS*, she remembers the symptoms in the last pregnancy, she is young, she is clearly progressing and she wants to take care of the children she already has.

What would YOU choose? For yourself, for your sister, for your wife. If you are male, do you have any right to make that choice? Now picture yourself pregnant with that choice. And thank you for reading this.

*Addendum: present evidence says that multiple sclerosis does NOT worsen with pregnancy. However, another illness, NMO (neuromyelitis optica) instead tends to become more active in pregnancy. It previously was lumped in with MS until the antibodies (anti-NMO) were identified and it was realized it’s a different subtype of demyelination disease, with its own treatment options. Medicine changes over time and the woman, the neurologist and I were working with the information available at that time.

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speaking up

A friend says he does whatever he wants. He refuses to answer questions about how he makes his money. He doesn’t care if this annoys people. I suspect he may enjoy it.

I have one of those public jobs. Well, had. I have now been disabled from Family Medicine for a year. My lungs are much better than a year ago but they are not normal. And I have now seen 17 specialists and 3 primary care doctors since 2012. The consensus is “We don’t know.” Though many specialists are not willing to say that. What they say instead is, MY testing is NORMAL, go to someone else. My lungs are not normal, but I am on my fourth pulmonologist. I saw a cardiologist this year and the first thing he says is, “It’s your lungs, not your heart.” Well, yeah, I know that.

I miss my patients, but there is something freeing about not working. Ok, more money would be nice, but I am doing ok. Meanwhile, I am thinking about what to do now. I can write full time. Write, make music, travel (on a budget) and sing. And speak up.

Doctors have interesting portrayals on television. We went from Dr. Kildare to Dr. House, working our way through the shows with an emergency room and medical residents. ER drove me nuts. No one EVER dictated a chart so at the end of each show I hyperventilated at the hours of paperwork/computer/dictating they had left. House interests me because it’s always the thing that the patient is hiding or lying about that is the key. “Go search his apartment.” says House. I have figured out cases by getting permission to call family or a group home. More than once.

But a physician is a public figure. I had been here for less than a year when a woman comes up to me in the grocery store and says “What are my lab results?” I look at her blankly. I can’t remember if I really did the snappy comeback that comes to mind: “Take off your clothes and I will see if I remember.” I respond politely and she says, “Oh. I should call the office, right?” “Yes, I try to leave the work there,” I say. If a particularly difficult person was bearing down on me, I would whisper “cry” to my kids. That worked. They would act out on cue and I would be the harassed mother. The person would back off.

I am in a small town. We have three grocery stores. I see patients everywhere, now that it has been 22 years. If I remember every detail, that means they are or were really sick. And we have the layers of relationships: someone might have kids the same age or work with boats or be in chorus with me. Once I take my daughter to a party. The mom introduces me to two other mothers. “She’s my doctor,” says the introducing mom. “Well, me too.” says the second. “And me,” says the third. We all laugh.

Once I am visiting my brother outlaw’s bicycle shop. He has a customer. The customer starts talking to me too. Brother outlaw says, “Do you two know each other?” The customer eyes me. I have my neutral doc face on. “She’s seen me NAKED!” says the customer and I howl with laughter. What a great reply. And my brother outlaw gets it.

Docs have to pay attention to HIPAA. When three women say that I am their doctor, I reply, “Yeah and I left my brain at work, so I can’t remember a thing.” Those three were healthy, so I really do not remember labs or the results of a pap smear. Once I was in cut off shorts and waved at an older woman who was at the ophthalmologist’s. She sniffs and looks away. I get the giggles: I think she did not recognize me. My town is only 10,000 people, so after 22 years I have taken care of many of them. Though sometimes people thank me for taking care of their mother, and after it sounds unfamiliar I ask if they mean Dr. Parkman? Oh. Yes. People get me mixed up with two other small Caucasian woman doctors.

I started the “outfits inappropriate for work” category last year when I was still very sick and short of breath and on oxygen. I did not go out much, partly to avoid covid. My pneumonia was something other than covid and it was my fourth pneumonia and I should not need oxygen. Now I’ve had mild covid and the oxygen is only part time. I sang at my son’s wedding, off oxygen, so I can sing off oxygen for a short time. I danced off oxygen too and did get QUITE short of breath. Since I am no longer a public figure, I can speak out and speak up more. I am thinking about that, particularly with the recent Supreme Court news. I do not agree with what they seem to be planning.

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Patient Satisfaction Score

The latest issue of Family Practice Medicine has an article on patient satisfaction scores.

I remember my first patient satisfaction score VIVIDLY.

I am in my first family medicine job in Alamosa, Colorado. I receive a 21 page handout with multiple graphs about my patient satisfaction scores. I am horrified because I score 30% overall. I am more horrified by the score than the information that I will not receive the bonus.

I go to my PA (physician’s assistant). He too has scored 30%. We are clearly complete failures as medical providers.

Then I go to my partner who has been there for over 20 years.

She snorts. “Look at the number of patients.”

“What?” I say. I look.

My score is based on interviews with three patients. Yes, you read that correctly. THREE PEOPLE.

And I have 21 pages of graphs in color based on three people.

I am annoyed and creative. I talk to the Physicians Assistant and we plan. I call the CFO.

“My PA and I think we should resign.”

“What? Why?”

“We scored 30% on the patient satisfaction. We have never scored that low on anything in our lives before. We are failures as medical people. We are going to go work for the post office.”

“NO! It’s not that important! It is only three patients! You are not failures!”

“Three patients?” I ask.

“Yes, just three.”

“And you based a bonus on three patients? And sent me 21 pages of colored graphs based on three patients?”

“Um…”

“I think we should discuss the bonus further….”

I did not get the bonus. It was a total set up and I am not sure that ANYONE got that bonus. Much of the maximum “earning potential” advertised was impossible for any one person to get. You would have to work around the clock. They got out of paying us by having multiple bonuses that each required a lot of extra work…. They were experts in cheating the employed physicians. That became pretty clear and I was 5th senior physician out of 15 in two years, because ten physicians got right out of there. I lasted three years, barely. I knew I would not last when an excellent partner refused her second year of $50,000 in federal rural underserved loan repayment to quit AND stayed in the Valley working in the emergency room. I called the CEO: “Doesn’t this get your attention?”

“She just didn’t fit in.”

“Yes, well, I don’t think anyone will.” I asked my senior partner how she stayed. “You pick your turf and you guard it!” said my partner. I thought, you know, I hope that medicine is not that grim everywhere.

Unfortunately I think that it IS that grim and getting grimmer. Remember that in the end, it is we the people who vote who control the US medical system. If we vote to privatize Medicare, we will destroy it. Right now 1 in 5 doctors and 1 in 4 nurses want to leave medicine. Covid-19 has accelerated the destruction of the US medical non-system, as my fellow Mad as Hell Doctor calls it. We need Medicare for all, a shut down of US health insurance companies, and to have money going to healthcare rather than to paying employees $100,000 or more per year to try to get prior authorizations from over 500 different insurance companies all with different rules, multiple insurance plans and different computer websites. Right now I have specialists in four different local systems. The only person who has read everyone’s clinic notes is ME because it is nearly impossible to get them to communicate with each other. Two of them use the EPIC electronic medical record but consider the patient information “proprietary” and I have to call to get them to release the notes to each other. Is this something that we think helps people’s health? I don’t think so. I have trouble with the system in spite of being a physician and I HATE going to my local healthcare organization. Vote the system down and tell your congresspeople that you too want Medicare For All and single payer.

Physicians for a National Healthcare Program: https://pnhp.org/

Healthcare Now: https://www.healthcare-now.org/

I have had people say, but think of all the people out of work when we shut down insurance companies. Yes AND think of the freedom to start small businesses if we no longer have to fear the huge cost of insurance: Medicare for all!

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Covert covid conundrum

I had covid recently AND I have been very lucky with it.

WHAT?

Ok, so when the war started I had been talking to a friend in Europe about visiting. He said nice seasons were May and September, but he and his wife have a kitchen make over planned for September.

“My son is getting married at the end of April, after two year long postponements, and so May doesn’t seem feasible. Maybe next May.”

Then the war starts. And it is affecting gasoline and causing inflation. I call my friend. “Can I come in two weeks?” March to early April.

“Yes. We have other guests a week after that.”

“Ok.” I try to get a British Airways ticket to stop in London to see an old friend from high school. British Airways has a computer attack and three days go by. To heck with it. I buy a ticket to Paris and on to my friend’s country.

I spend an hour on the phone trying to change to a layover in Paris for three days. I manage that. I fly to Paris and then take the train to London. Three wonderful days with my friend in London. I mask on planes, metros and trains. I double mask on the airplane, with my oxygen, and use a ceramic straw to drink liquids.

After three days I take the train back to Paris, the local train to the airport, and fly to my old friend’s. I arrive at midnight and we take the metro.

We do lots of sightseeing and take a memory trip to his parents’ graves and the town we lived in when I was 17 and he was 18.5. I was an exchange student. The language comes back. I can read but listening is more difficult. My brain won’t process it fast enough.

Four days before I am due to fly back, I get an email from AirFrance. I need a negative PCR covid test within 24 hours of flying to return to the US.

Well. I have a mild headache and muscle aches. Probably not covid, BUT. I go online, register in the country for a test and go to the testing site. Positive. I read about covid. The muscle aches of this strain usually happen at day 4-5. I did notice that going from London to Paris to my destination four days earlier, I feel a little off balance. Not bad, not spinning, just slightly weird. So my guess is that I am at day 4 or 5 of covid.

My hosts have both had covid within the last month, so I am not confined to my room. I read the rules for being allowed on the airplane once you HAVE covid. I have to wait 11 days, have a certificate of the test and then the eleven day certificate saying cleared. I isolate for 5 days, spend about 8 hours rescheduling the flight with Air France and Delta, and contact my doctor. My doc wants me to take medicine, but the local medical people where I am say I am not sick enough. I agree with the local people. The headache is gone the next day, I have mild sniffles, and my lungs are fine. Well, at least, they are no worse.

When I am out of isolation, I take a train to another town masked and stay at a hotel for four days. In that country, 80% of the people are vaccinated and 80% have had covid. They are no longer masking, except a few. I am feeling good. I mask when I am around other people and in all public spaces in the hotel.

The trip home is rather more exciting than I would like. At the airport I am informed that I need a doctor clearance ALSO. They say retest. I say “I AM a doctor.” and pull out a copy of my license. I brought it just in case the war spread and I needed to help out. They let me on the plane. In Paris I nearly miss my connection, but am one of the last 8 people on the plane. I am very relieved once we take off.

The silver lining is that at my son’s wedding I am now very unlikely to get covid or give anyone covid and mine was very mild. The Omicron BA2.12.1 that is circulating in Europe is milder than the previous strains AND ten times more contagious or more. So the covid is morphing towards a cold, which is what coronaviruses used to do to us. There are some strains that I read about that are going in a more virulent direction, so I would prefer to have the mild one and be protected from the nasty ones.

Here is the CDC section about strains in the US:

https://covid.cdc.gov/covid-data-tracker/#variant-proportions

I arrive home on April 12 and then am unsurprised to see covid cases starting to rise again in the US. Here is the CDC tracker: https://covid.cdc.gov/covid-data-tracker/#datatracker-home

I am hoping that it’s more and more Omicron BA2.12.1, since it seems to be milder. I am reassured that covid did not make my lungs worse. Within a week I am better from covid and then get what seems like a normal cold. Covid testing negative. I am feeling well for the wedding and reassured that a normal cold does not force me on to continuous oxygen. I am feeling lucky about the version of covid that I have but I am NOT recommending that people get it on purpose, because even with mild covid, some people go on to develop long covid. Here is an article that I got yesterday through the American Academy of Family Practice:

https://www.healio.com/news/infectious-disease/20220425/global-prevalence-of-long-covid-substantial-researchers-say

Long covid is very worrisome and we don’t know what it will look like after a year or more. Many of the present studies are on unimmunized people, from the first year of covid, so the studies of immunized are still evolving. There is hope that there is less risk of long covid with immunization but there is still a risk.

Covid will continue to morph into different strains. We continue to get “colds” or “upper respiratory infections” because the viruses are very very good and fast at changing and avoiding our immune systems. Consider checking the CDC data tracker above regularly to see if your county or your destination has a high covid level and if so, mask back up.

One caveat: my local health department says we have a high level of transmission right now, here:

https://www.jeffersoncountypublichealth.org/1429/COVID-19

while the CDC says low, here:

https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=Washington&data-type=CommunityLevels&list_select_county=53031

Remember that all of these sites have to exchange data and update everything. My best guess is that the local has the best numbers, but that is a guess.

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mountain 2

It is gracious of the mountain to show herself the day after my son and daughter-in-law’s wedding. I stay in a rental house with two aunts and an uncle (all in their 80s), my daughter, and two old friends and their son. The age range is 13 to 86. When the fog and clouds fall away from the mountain we all rush for our cameras.

For the Ragtag Daily Prompt: gracious.

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FINIS!

Whew! I finished the AprilAtoZ blog challenge even with a wedding and not just a wedding but MY SON’S WEDDING on April 30th! Extra challenging. Two weeks before April 30th I started working on two posts a day, working backwards from the end of the alphabet and forwards from where I was. I set them to post on the appropriate days!

I have until May 7 to write a reflections post, but not today! I got home at 5 pm and it has been terribly exciting and rather complicated too. Weddings during covid turn out to be challenging, but my son and my new daughter are a delightful pair. I said that she has been a daughter for a long time now and she says that she felt like my daughter the first time that she got two pairs of wool socks in her stocking at Christmas….. That has become a family tradition.

Hooray for weddings in spite of pandemics! This one was postponed twice but is now complete! Blessings on everyone and thanks.