Tag Archives: teamwork

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Keyboard supervisor

Elwha supervising me at the keyboard.

In high school I took typing for dummies. I was terrible at it and slow. Many women were avoiding typing classes in the late 1970s because they did not want to be secretaries. I wanted to be a writer and knew that I was a terrible typist. I also could not spell my way out of a paper bag. My mother was quite dyslexic and did not care. Once I had to sound out a word at the store from her grocery list: “LETIS”. Oh. Got it. Her letters are wonderful, not only interesting and creative spelling, but also wandering tenses and subjects.

We got our first electronic medical record in the early 2000s. We went from looking up labs on a computer and using a computer for maybe an hour total per day to full on eight hours a day. My shoulders and the nurses’ shoulders all locked up and we all filed for Workman’s Comp. I had to work with physical therapy to get my shoulders to unlock. My nurse pointed out that all problems were treated as “User Problems”. That is, WE were the problem, not the program. I realized that having the doctors who love computers pick out the program, learn about it for a year, and then teach us in two days and go live was a massive mistake. None of us understood it nor did we understand any of the computer lovers’ terminology. We rapidly quit asking questions because we didn’t like being treated as morons. Every person who was not a computer lover figured out their own work arounds. Two years later, the computer lovers tried to get us to standardize what we were doing. It’s not very surprising that we resisted and hated them. We had had to figure it out on our own with no help and we were very cynical and disbelieving that they would now “Make it easier.” Nope, they didn’t.

If I were to do it over again, the team picking the electronic medical records would include a couple of older doctors who hate computers. One of the selling points to the computer lovers was “you can write your own templates”. Our response was “We would rather be boiled in oil.” Three years after we got the system I asked the head computer lover doctor to write me a template. It was generic. Patient is complaining of (a problem) (more than one problem). The (problem) has been present for (a day, two days, a week, a month, a year, too long). The problem is (getting worse, the same, getting better). And so forth. Because we had all sorts of problems that did not have a template. My computer lover doc rolled his eyes, but set it up for me.

I also asked the clinic CFO WHY they didn’t set up typing lessons for the doctors who couldn’t type. I watched one of our group hunt and peck with two fingers. “You want them faster, right? You’ve said we could do the whole note in the room. How can they if they can’t type?”

“We are not giving them typing lessons.”

“Well, I think that’s misguided.” Ok, what I meant was that I thought it was STUPID.

Another selling point was that we could finish the note in the room. It turned out that I could do the note in the room after I had fought with the program for two years. It consistently took me 25 minutes. Then they ramped up the schedule and set us all at 20 minute visits. I started running late all the time. I told the front desk, “I’ve been told I should get the note done so I am. And if it takes me 25 minutes, that is what it takes.” Once the hospital kicked me out, I started my own clinic and did 30 minute visits. This did not make me rich but it made me a heck of a lot happier.

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For the Ragtag Daily Prompt: keyboard.

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This too two to

This two too to I want to remember.
Licking? Touch for certain, together.
Warmth and safety and rest and trust.
The trust eroded as you run away
over and over. You say always but
you say other things that I can’t believe.
And yet my heart is stubborn still.
This two too to I want to remember.

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Poem series: This. This too. This too two.

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hands together

These hands and the other hands that finished this difficult puzzle together on Christmas morning. We even found the missing piece, under my son’s pile of loot! We did start this one two days before Christmas. It’s a stinker.

These hands that make eggs benedict, and hug me, and hug each other. These are some of the things I adore, the owners of these hands.

For the Ragtag Daily Prompt: adore.

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All of my patients are smart 2

I did a porch call a bit over a year ago. It’s like a house call except on a porch.

A friend/patient asks me to see a long time friend of his. The friend has multiple chemical sensitivities. We meet, the three of us, on his porch.

My friend has had me as a physician but he has not seen me at work with someone else.

I ask a lot of questions and then launch into an explanation of the immune system and how antibodies work.

My friend states, “He can’t understand that.’

I smile at his friend. “Oh yes he can. And you followed what I said, didn’t you?”

His friend grins back and said, “Yes, I did. Most of it. Or enough.”

All of my patients are smart. One day in clinic I think how blessed I am, that ALL of my patients are smart and fascinating people. Then I think, how could that be? And, how lucky am I?

And then I think: everyone is smart.

They are not all educated in the same way I am. They may not be well read. They may not have my science background or my geeky fiction and poetry and song brain. But they ALL are smart.

Some are brilliant at mechanical things. I have a patient who is an expert in restoring church organs and is working 3000 miles away in New York City. “They are driving me crazy.” he says. “You have to have the approval signed off on over 20 groups, historic preservation, the fire fighters, etc, etc, to remove one board from the church. The organ was covered over by bad repairs over the years. We’re trying to get it back. After this I will put in new organs, but this is my last restoration.”

Veterans, teachers, attorneys, physicians, retired computer engineers, car mechanics, marine engineers, parents, grandparents. They are all smart, men and women.

We finish the porch visit with some options and the friend of my friend says he will think about what I said and try some things.

A few days later my friend calls. “I couldn’t believe he was following your science talk, but he was. He got it. He remembers it and understood it.”

“Of course he did,” I say.

“I am actually impressed,” says my friend. “It was really interesting watching you do that.”

That may be one of my weird skills. To be able to listen to the person thoroughly and then respond in language that they understand and a bit more. An assumption, always, that they can follow a complex and intricate idea.

I do not know if they always follow what I say. But they always respond to the assumption that they are smart and that they can understand and that they are an equal. I am explaining from my expertise, but I know they can understand when I explain it correctly.

And I have not seen this in the physicians that I have seen. Out of 22 physicians since 2012, four were excellent and met me and explained as an equal.

The rest did not. They dismiss me. They talk down or avoid me once they realize that they do not understand why I keep getting pneumonia. They are afraid to say “I don’t know.” Four are not afraid and recognize that it’s something weird and say, “We do not understand this and we don’t know how to fix it.”

Four out of 22 have my respect. And that is a sad number. Medical training needs to change and physicians need time to listen and need to learn how to listen.

Meanwhile, all of my patients are smart. And I am so blessed.

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Reblog: Desertification

I don’t want to argue about global warming. Let’s talk about deserts instead. Overgrazing, cutting down all the trees and losing topsoil: we have seen this in the United States, with the dust bowl. We have a lot of people in the world to feed, even after all the deaths from Covid-19. We need to take care of land.

https://desertification.wordpress.com/2022/10/08/healthy-forest-project-launched-to-protect-mongolia-forests-for-future-generations/

Ok, I am lame, that is embedded, not a reblog. I will have to figure out the difference. Feel free to laugh at me. My problem with technology is that it is NOT intuitive. I was horrible with computers until I realized that they are linear and stupid. That is, they only follow the exact right command and they have very little capacity to guess what I mean. I decided that computers were glorified hammers and very very annoying and that the manuals are usually written by people who speak computer, not English. That made it much easier for me to work with computers.

Anyhow, plant a tree. Blessings and peace you.

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Adverse Childhood Experiences 14: Hope

I keep reading bits about despair and about how a generation of children is being “ruined” by the pandemic.

Not so, I say. There is hope. We need to support each other to survive and then to thrive.

This generation WILL have a higher than average ACE score. If the Adverse Childhood Experience scale is from zero to eight, children in this time period will have at least one higher point than average and many will have three or four or more. Loss of a parent, a sibling, beloved grandparents during covid. Increases in domestic violence, child abuse and addiction. These are all part of the ACE score.

What does this do to children? They have survival brain wiring. They will do their best to survive what is happening. A friend and I both have high ACE scores, 5 or more, and we are both oppositional defiant. We showed this in different ways. He grew up in the same community. He escaped from home and knew all the neighbors. He walked to the local church and attended at age 3 or 4. He has lived in this community all his life.

His oppositional defiance showed up at home, where he consistently refused to obey. And in school, where he confounded and disobeyed teachers and passed anyhow.

My family moved every 1-5 years. I hated moving. I wouldn’t talk to kids in a new school for a year. It was very difficult. So my oppositional defiance was very very internal. I hid in books and in my head. In 6th grade I got in trouble for hiding novels inside the school book I’d already read. I also would just not listen and my respect for the teacher got even lower when she would be angry that I knew the answer to the question once she’d repeated it. I wasn’t listening because I was bored. She was the first teacher that I thought, well, she is not very bright. The next year they stuck me in the honors class and I stopped being bored, though I still questioned practically every opinion every teacher had. I wanted evidence and I did not believe it just because the teacher said it.

I am not saying that oppositional defiance is in every high ACE score. I don’t know that. Why oppositional defiance? Imagine you are a small child and you are beaten. There isn’t rhyme or reason. You can’t predict when the adult will be out of control. Why would you behave “well” if it makes no difference? You might as well do what you want, because nothing you do will change the adult. Or imagine you are a small child who is with one person, passed to another, then to another. You may not exactly trust adults after two or three repetitions. And you want to survive.

There is an increase in addictions, behavioral health diagnoses, and chronic illness in adults with a high ACE score. A researcher when I first heard a lecture about it said, “We think perhaps that addiction is a form of self medication.” I thought, oh, my gosh, how are we ever going to treat THIS? Well, we have to figure that out now, and we’ve had 30 years to work on it.

I was very comfortable with the oppositional defiant patients in clinic. I got very good at not arguing with them and not taking their behavior personally. They might show up all spiky and hostile and I might be a little spiky and gruff back: sometimes that was enough. I think the high ACE score people often recognize each other at some level, though not always a conscious one. With some people I might bring up ACE scores and ask about their childhood. Sometimes they wanted to discuss it. Sometimes they didn’t. Either was ok.

One thing we should NOT do is insist that everyone be “nice”. We had a temporary doctor who told us her story. Her family escaped Southeast Asia in a boat. They had run out of water and were going to die when they were found by pirates. The pirates gave them water. They made it to land and were in a refugee camp for eight years or so. She eventually made it to the US. She was deemed too “undiplomatic” for our rural hospital. I wondered if people would have said that if they knew her history and what she had been through. It’s not exactly a Leave it to Beaver childhood, is it? When she was telling us about nearly dying of thirst in the boat, my daughter left her chair and climbed on my lap. She was under ten and understood that this was a true and very frightening story.

We can support this generation of children. This has been and is still being Adverse Experiences for adults as well. Family deaths, job loss, failure of jobs to support people, inflation. Remember the 1920s, after World War I and the last pandemic, of influenza. “On October 28, 1919, Congress passed the National Prohibition Act, also known as the Volstead Act, which provided enabling legislation to implement the 18th Amendment.” (wikipedia). There were forces trying to legislate behavior, as there are now. The result in 1920s of making alcohol illegal was speakeasies, illegal alcohol, and violence. Some people acted wild after WWI and the influenza pandemic and some people tried to lock down control, by controlling other peoples’ behavior. It did not work then and it will not work now. The wildness is out of control grief, I think, grief dysfunctional and drinking and shooting and doing anything and everything, legal or not. We remember how the 1920s ended too. Let us not repeat that. Let us mourn and grieve and support each other and support each other’s decisions and autonomy.

Blessings.

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city versus country

A friend comments that the country used to outnumber the city folk but now it’s the other way around, and that the split in our country is about values.

Hmmm. I am thinking about that. I am a city girl AND I am a country girl, both. We moved every 1-5 years and I was in cities and in the country. However, my family also had two anchor points. My mother’s family has shacks on a lake in Ontario, summer shacks. My father’s parents had a house on the beach in North Carolina on the outer banks. Wind and water in both places and we never watched tv in either place, because we were outside until we fell exhausted into a tent or into bed.

I don’t agree with my friend. I think we ALL share some values: that no one should go in a school and shoot kids, or a church and shoot people, or a store and shoot people. Right? We all agree on that if we are sane. That is a starting point. I read the mediation books when my (now ex-) husband was getting certified. The mediators start by trying to find the common ground.

I am pretty much equally comfortable in my small town, the woods, on the water and in cities. My friend warned me about Seattle being dangerous now. Well, it’s a matter of scale. I went to high school in Alexandria, Virginia and I lived at 3rd and Massachusetts in Washington, DC back in the 1980s. I was pretty careful just walking to the metro in that part of Washington at that time. I pay attention in Seattle, but in these cities I know what I am paying attention to. I ended up alone on a metro car once at night. A man got on at the next stop, looked around the car, grinned and came and sat next to me. I thought, oh, Sh-t, this is not good. I ignored him and continued staring at my book.

“Hi, what’s your name?” he says.

“I am reading.” I say coolly.

“Come on, honey,” he says.

I shut the book, stand up, and he lets me pass. I stand by the metro door until the next stop, get off that car and get on another car with more people. The car did have emergency alarms, so I could have hit one, but he let me by so I didn’t. I was kicking myself for being alone on the car, but honestly: what a stupid nasty male chauvinist threatening jerk. I shouldn’t have to worry about this crap. But after that, I didn’t get lost in a book on the metro because I had to pay attention to avoid being alone on a car. Annoying as can be.

My friend says he gets lost in cities. I don’t. I start building a map in my head when I arrive in a new city. It is completely automatic. If I am driving, it’s based on the highway. If it’s by airplane, it includes the airport, the hotel, the conference center. I have been to San Antonio once, but I stayed at a hotel along the River Walk and the conference center was towards the center and south. I could draw part of the city, still. I love maps!

I can’t say that I would be comfortable if dropped in a city in another country, necessarily. I was pretty happy on my trip in March, which was abroad. There are levels of familiar and what are the languages in common? Are there any?

What are these values that people might be split on? I read that people are polarized and can’t get along, but I don’t agree. I did Family Medicine in this town of 9000 for 21 years, and I had people from town, from the county and eventually from three other counties. I had nine people who had to take a ferry to see me. Talk about inconvenient for them. My people are all races, all genders, age zero to 104, all different stripes of politics. I don’t care what their politics are: I am there to see if I can maintain or improve their health. This could mean anything from encouraging exercise, doing a pap smear, diagnosing diabetes to discussing hospice and end of life issues or telling someone that I do not think they are safe to drive. This is not about “pleasing” people: recognizing opioid overuse in a person does not endear me to them. But it is about doing the best I can for people and with people. And isn’t that a value we all share too?

Now we have common ground, two areas to stand. Grow that space. Peace me, work for justice and kindness and peace to you.

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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!