Thursday, April 27, 2006
I was running late. I was hungry. I hadn't eaten since breakfast, a cup of coffee and a banana. I was on my way to therapy, a half hour drive followed by an hour of intense mental calorie burning, followed by a half hour drive home. The blessed vessel needed fuel.
My ravenous eyes spotted a Wendy's on the other side of the street. Screech! Swerve! I cranked the G's on my '89 Volvo, took the turn at a blistering 18 mph, and pulled into the drive-through.
"Welcome to Wendy's, may I help you?" A remarkably clear woman's voice issued from the speaker box.
"An order of fries please. With mustard" (don't knock it 'til you've tried it).
"A dollar thirty two at the window, please drive forward."
Taking my foot off the brake pedal, I let the volvo inch forward as I rummaged in my purse for money. When I saw the window out of the corner of my eye, I stepped on the brake and continued rummaging. A dollar...a quarter....a penny...I became aware of a figure at the window. "Sorry, I'm just looking for exact change."
"It's all right. Take your time." The same clear voice that had come from the box. Finally giving up on finding the right change, I grabbed another dollar bill and looked up to hand her the money.
Doctors get used to surprises. We see and hear so many unbelievable things that eventually everything is believable. You put a noodle in your nose? No problem. You drink a quart of rotgut every day? I see. Your parents locked you in a dark closet? Tell me more. From the laughable to the horrific, we learn to react with no reaction. It wouldn't surprise me to hear that the best poker players are ER docs.
I was grateful for this training when I saw the face in the window. The woman (I only knew it was a woman because I had heard her voice) had obviously been in some kind of terrible accident. Her face contained all the right parts, but in all the wrong places. It looked like a wax sculpture that had been left in dappled sun to melt unevenly. The result was a hideous gargoyle mask. Scar tissue twisted her mouth into a grimace. Her eyes were pinched and uneven. Her nose sat askew. One whole side of her face was shorter than the other. To say it was shocking is a gross understatement.
"Here you go. I couldn't find change." I handed her the bills, smiling normally, I hoped. As she turned to the register, I imagined the reactions she must get from the hundreds of people driving through here every day. Many of the cars would have kids in them, kids who don't control their words or faces. Did she hear cruel comments? Laughter? Shocked gasps? Did she see stares of pity and horror? Embarrassed averted faces? Probably all of the above and more. The scarring was not new. She had lived with this for a while.
"Thank you, have a nice day," she said, handing me my fries and mustard.
"And you," I replied, and pulled the volvo away from the window, my bouncy mood sobered by admiration.
Kudos to Wendy's for hiring her. Kudos to them for seeing the woman behind the mask and giving her the job she was capable of. Kudos and more kudos.
But double, triple, quadruple the kudos to her. She didn't hide. She didn't hole up at home. She didn't find work in some back kitchen or night janitor service. She took a job that literally put her front and center. She chose to meet the public's eye day after day after day. She is as brave, in my opinion, as any warrior.
I will never forget that face, not for its contorted appearance, but for the powerful courage that burns behind it and shines through it. I have added another hero to the ranks.
Wednesday, April 26, 2006
The Susan B. Komen "Race for the Cure" for breast cancer is coming up. Last year, one of our staff was post-op from her own case, so I organized a team to walk/run in support of her. We called ourselves The Brassieres (in support, get it?). I ordered a bunch of white baseball caps and went to the thrift store and bought the gaudiest bras I could find. We then decorated the caps with the bras [arrgh, here's where I wish I had more cyber-smarts: I'd insert a photo], augmented a bit with craft stuffing, glitter, etc. They looked totally ridiculous and hilarious. We had a great time, and we won the Team Spirit award.
Sometimes once around is enough for a good idea, so we're looking for a new name for this year's team. We'll need a new costume or gimmick to go with it. Some of our ideas so far are:
Sarcastomas in Situ
We welcome more witty suggestions from any and all smart alecks.
This year, I will be holding in my mind a relative and a patient, both recently diagnosed. The staff person who was benched by surgery last year is back in the game and on the team, so we'll be celebrating too!
Monday, April 24, 2006
Saturday, April 22, 2006
If anyone knows the whys of this and how to fix it, please tell me.
Today was the first day I went to see her. I meant to go before. I thought about it from time to time, but there was always some reason I couldn't go. It was too late in the day. I was ill. I was out of town. I was too tired. I forgot. I heard she had too many visitors. I forgot again.
As I walked in there today and felt my pulse rise and my sweat glands pop into action, I understood that what had kept me from visiting before today was simple fear. Iced with denial. I was afraid of how I'd find her. I was afraid of her debility. I was afraid I would be unable to be natural with her. I was afraid of her fear. Of her mortality. Of my mortality. Of that sneaky devil Bad Luck, or Mischance, that cruel and random force that strikes out of the blue .
She looked like herself. Except for the scar across her head and the shadows under her eyes. She recognized me. She spoke in complete sentences. She stood to hug me and only wobbled a little. Some of her words were slurred and she didn't seem to hear everything I said. Sometimes her thoughts jumped randomly. I had been warned that this was happening. She still has swelling on the brain, and blood. It will take time to see whether she will recover completely or not. She's lucky to be alive.
A scant hour before I went to the rehab hospital, I attended my own service recognition ceremony at the University, along with two hundred others. I stood in line, received my handshake and token gift, applauded for the others, wondered how 15 years had flown by so fast. While the other honorees lined up, I sat yawning in my seat, sneaking looks at my reading book between claps, wondering what kind of food they'd have at the reception. I was frankly bored.
An hour later, sitting next to my friend on her hospital bed, I felt chagrined. Here she was, struggling to form a complete sentence, and I had been bored with the service anniversary ceremony. I should have spent that time awash in gratitude. Gratitude that I was alive and well and capable of working fifteen years.
I take my health for granted. I take my life for granted. I forget to be grateful.
There's nothing like the illness of a friend to put things in perspective.
Saturday, April 15, 2006
I could say all those things, but I'd be lying like a rug.
The truth is, doctors are just as human as anyone else. We have bad days. We have buttons. We get tired. We get PMS. We feel anger, frustration, annoyance and fear. We don't treat all patients equally all the time. We don't even like all patients equally all the time.
Now, I'm hardly one of those crusty curmudgeon docs. You know, the ones who bang in, barely look at you, bark orders, scribble in the chart and bang out. I'm usually quite nice to my patients. And I usually DO feel love and compassion. I truly enjoy my work, and feel honored to do it. But there are those times...
I'm going to describe a few patient "types" that predicatably get my dander up. If you recognize yourself here, cancel your appointment and find another doctor! Just kidding. My goal here is to add data to my "doctors are people too" hypothesis, and to raise awareness in people who might inadvertently be pushing their doctor's buttons. I'll alternate gender to be fair, because any of these can come in the male or female variety.
First there's The Late Mr. X. No matter how far in advance this one made his appointment, he always rushes in late, in a panic, almost too late to be seen. He drops stuff everywhere. He apologizes profusely every time, citing various plausible causes of his tardiness, none of them his fault. He charms his way into the exam room, backing up the whole line behind him. He honestly doesn't mean to be a pain. He was trying to be on time. He was planning to be on time. He probably has Adult ADHD. He's probably late to everything, bless his heart. Bless his heart, but curse his timing!
Laundry List Lily is the patient who schedules a brief appointment for "follow up" or "single problem" or "to discuss something with the doctor; it'll only take a few minutes." Then, when I ask her to tell me about her problem, she pulls out her list. A litany of complaints, none of them brief or simple. She really needed a long visit. Or three. If I address all of these today, it's going to delay everyone after her and make me late. And grouchy. In residency, I was told to Just Say No to the Lily's. Tell her we can deal with ONE problem only, and she'll have to reschedule for the others. This is easier preached than practiced. It might take weeks for her to be able to get back in. She's here now, she's already listed her problems, and oh, what the hell, let's just do it. Lily honestly doesn't mean to be a pain either. She probably thinks problems are easy for me. I think she might have low self esteem, might be unsure that she is worthy of much attention. When in reality she's worthy of much more than she asks for.
The Drama Queen is one of my personal least faves. I always imagine this one with her hand against her forehead, palm out. You know, the old "woe is me" pose. Her highness speaks in dire pronouncements. "I can't breathe." (This is while she is speaking clearly and calmly, thus obviously capable of breathing.) "I can't walk" (after strolling into the clinic with no assistance). "I haven't slept in a year" (blatantly impossible). Doctors are scientists, remember? We don't like broad sweeping exaggerations. We like data. We like precision. "I often cough when I breathe." "It hurts right here when I walk." "I've been having trouble falling asleep for 3 months." Patent impossibilities tend to lose you respect. Perhaps The Drama Queen would be more aptly named The Boy Who Cried Wolf. Remember what happened to him?
Thankfully rare is Eric the Entitled. In my Student Health Walk In Clinic, this one is often a medical student, I'm sorry to say. He is terribly, importantly busy, and really deserves to be seen quicker than anyone else. He absolutely can't get away from his essential role to make an appointment. He must be seen now. Oh, and he knows exactly what he needs. Don't ask him all these unnecessary questions. Just give him the precise medication he wants. And, of course, call him on his cell the minute his results are in. If you don't, he'll feel entirely free to just drop in and interrupt you so he can have the information at his convenience. Does Eric know he's a pain? Probably, but he just doesn't care. How do I feel about Eric? The truth is I just wanna wring his righteous little neck.
The Ventriloquist is actually not a patient, but a spouse, partner, or family member who comes with the patient and answers all the questions directed at the patient. "So, Mr. Smith," I say, making eye contact with the patient, "Tell me about your rash." Before Mr. Smith can open his mouth, The Ventriloquist pipes up. "He's had it since we went in that hot tub at the hotel." I listen politely, turn back to Mr. Smith, and, when he doesn't offer anything further, I ask my next question. "Does it itch?" Again, The Ventriloquist. "It itches like crazy! He's scratching a hole in his pants!" Etc, etc. (The extreme version of the ventriloquist is The Controller, who might be an abuser in thin disguise and who is not one bit funny). The Ventriloquist can only be silenced by Banishment to the Waiting Room.
Drug-seeking Dan is one that all doctors know. He comes in different shapes and sizes, he uses varying strategies, but his goal is always the same. Only the story changes. " Someone stole my meds. I lost my prescription. My regular doctor is out of town so I can't ask her for a refill. I accidentally dropped the bottle in the toilet. The dog ate it." and other variations on this theme. The strangest ones are sometimes true ("my ex-wife threw all my stuff on the lawn and burned it"). The other clue that you might have a Dan on your hands is when he says something like, "I have this recurrent pain problem [with no physical findings] and it's back again and ONLY Percocet [or other specifically named medication and dose] works for me."
Dan is looking for a gullible, kindly practitioner to sucker. This used to be me, but I've toughened into a cruel bitch over the years (or so Dan has informed me). To avoid being mistaken for this miscreant, get your meds filled on time by your regular doctor, and keep track of them!
Roundabout Robin has never met a question she didn't like. And she never answers with a single word. You ask Roundabout Robin one of the open-ended questions that work so well with other patients, and you soon wish you hadn't. The answer to "How's your breathing?" might go something like, "Well, I remember back when we lived on the ranch, and my daddy had that old pickup, and we used to ride in the back when he went out to count the herd, and that dust would just blow up in our faces and make us cough like crazy, and I couldn't hardly breathe, it was so awful, but I could never ride up front in the cab because Daddy always saved that seat for his stupid dog..." Get my drift? As a doctor, you learn quickly not to ask Robin open-ended questions. You stick to simple, yes or no questions, figuring you can't go wrong with those. "Have you ever been hospitalized?" That oughta work, right? Only two possible answers to that one. You have, or you haven't. Right? WRONG! Roundabout Robin is incapable of speaking in one-word sentences, remember? "Oh, one time, I was so sick, and my sister, she kept telling me I oughtta go to the hospital, but I didn't want to go because I had a roast in the oven, and I knew I was really sick because every time I opened the oven to baste that roast, I threw up on the new linoleum floor we just laid the week before, so..." Roundabout Robin is the only patient I am rude to on a regular basis. I can't help it. If I don't interrupt her, we'll be there all day, or else I'll end up in the clink for strangling a patient, and then I wouldn't be there for her next time. So I have to be rude, right? Right?
Last (always last), By-The-Way Bill. Also known in the medical world as the Doorknob patient. This is the guy who, as you have your hand on the doorknob ready to leave the exam room, says, "Oh, by the way, I have this crushing sensation in my chest, like an elephant sitting there...." Screech! About face. Why didn't you SAY SO IN THE FIRST PLACE?! It's always something potentially horrible, this last-minute problem. And sometimes it's more than a potential. In fact, medical folklore is full of "doorknob disasters", where that tossed-off comment sets off an avalanche of major workups and often hospitalization. Like a little Smart Bomb. Bill doesn't actually annoy me as much as worry me.
I'm sure I'm leaving some out, but I'm starting to feel like Whining Winona here so I better quit and think about something more pleasant (like..... flowing myrrh!) before I get really grumpy. I can't afford an Attitude Adjustment on my government salary.
Thursday, April 13, 2006
I remember exactly what I need until the moment I leave the room in search of it. It’s as if a magic breeze flows through the house, sweeping my mind clean of its every intention the moment I cross a sill. Gone. Empty. Forgotten. I stand there, bemused, searching for the thought I had possessed a scant moment before. Where was I going? What was I looking for?
If I fight it, if I get angry or frustrated, if I grieve my aging acuity, all is lost.
But if I stand receptive, in silence, lo and behold. The currents swirl, the breeze comes around again. Gentle as a settling leaf, it drops my thought back into my head, and twists away chuckling.
Tuesday, April 11, 2006
goo la la
love lotion #9
cream of aphrodite
slippery sex saki
vagensation (a combo of "vagina" and "condensation")
I expect that just about exhausts this particular subject.
Next up: "Impatient Medicne"
Friday, April 07, 2006
There was a guy on the exam table, fully dressed, shoes firmly on feet. He was here for a sore throat.
Now, here's the dilemma. Do I address the foot issue or not?
A confounding factor is the structure and flow of the Walk In clinic, where I was working that day. We have several exam rooms, several practitioners, and a steady flow of patients. The practitioners don't have assigned rooms. Once I finish in one exam room, I move on to the next waiting patient, whatever room they're in. We just go along, taking turns and going to where we're needed next.
I had no idea who was in the room before this guy, nor how long he had been waiting there. Maybe it was the patient before him who had stunk up the place, and my patient's feet were clean as a whistle. Maybe I was making a false accusation, and would just anger the patient and make the clinic look less than pristine by calling attention to the choking fog.
Setting that aside as the lame excuse it is, the real question remains. Assume that I know that this pharyngitic person (big word for sore throat) was the odorous culprit. What do I do? He didn't ask to have his "foot problem" addressed. He's here for a sore throat, feels miserable, wants to get help and get back to bed. Should I say, "By the way, I'm noticing a distinctive, um, odor in the room, reminds me of limberger cheese..." Just kidding. I'd be more professional, of course! I would!
But should I? Do people expect their docs to address every health issue at every visit? Or do they want us to stick to the subject at hand, particularly in an urgent care setting? Would I be rude to mention someone's terrible acne, or remiss not to, when they're here for a sprained ankle?
As a Family Doctor, trained to view the patient as a whole organism, I tend to err, if you will, on the side of addressing rather than avoiding. Certainly if the "other issue" contributes to the problem at hand (like smoking when they have a respiratory infection) I feel compelled to mention it. It's bad medical practice if I don't. But something like smelly feet with a cold? I can't concoct a connection there, so addressing it is in the realm of "unrelated other".
What should I have done? What would you do if you were me? What would you want me to do if you were the patient?
Monday, April 03, 2006
"Think about the word 'vagina'. I believe that by saying it 128 times each show, night after night, naming my shame, exorcising my secrets, revealing my longing, was how I came back into my self, into my body."
Vagina. Vagina vagina vagina vagina.
When I was a girl, I didn't know the names of my private parts. I don't think we even called them "private parts". It was all vaguely referred to as "down there". Until the day one of my elementary school classmates, who had an older sister versed in These Things, informed us knowingly that the word was "vovey". So we called it "vovey", when we called it anything, when we dared to even speak about it, which was never, and only in a whisper, and only to each other, of course. One bold day, a friend and I revealed to each other that our "voveys" produced a secretion, which we gigglingly dubbed "vovey goo".
Twenty years later, I was a licensed physician with my own little girl. I knew the human body inside and out, and I was damned if my daughter was going to grow up without words for all of her body parts. I taught that kid "vulva" before I taught her "elbow". I wanted her to be proud of her body, to be comfortable with all of it. Naming was the first step.
[I knew that I had succeeded beyond my wildest dreams when she once shocked a Texas church potluck by standing in the middle of the room, pointing at each grey-hair in turn, and correctly identifying their gender by announcing, "YOU have a penis. YOU have a vulva." She was three years old. ]
In medical school, we learned anatomy the first semester, in the lecture hall and in the dissection lab. It was presented in an orderly fashion, head to toe. Where there were gender differences, the male anatomy was always presented first, followed by "the female version of this is..." Sure, it bothered me, but it fit in with the sexism that pervaded medical education.
When we got to the genitals, we learned the male anatomy first, as usual. I was amazed at the quantity of labels on the drawings, the number of named parts men have. Corpus cavernosum. Corpus spongiosum. Root. Bulb. Crus. Shaft. Corona. Prepuce. Glans. Four different named segments of urethra. Etcetera, etcetera, etcetera. I took notes dutifully.
Next slide. Female anatomy. Far fewer labels. Much briefer rundown by the teacher. As he prepared to switch slides, I raised my naive hand. "Excuse me. What are the names of those muscles?" I pointed to the striated bands surrounding the vagina at varying angles.
The professor looked confused. "What muscles?"
I showed him again.
"Oh. Those...uh, that....that's Vaginal Wall." Click. Next slide.
Now, wait a minute. I'm a woman, and half of my readers are probably women. Ladies, you KNOW that is not just one big muscle there, and it's not only useful for "holding your bladder" either. I was shocked that there weren't at least three different muscle groups in the vagina. Come on! The male urethra, a single tube, has four different named segments. But one single catch-all label for the mysteries of a woman's depths? Puh-lease!
That was a long time ago, now, and I've (clearly) gotten over it. But that morning, hearing Eve Ensler, it all came back to me again, and got me thinking some more about this male/female naming discrepancy. I remembered "vovey goo" and contemplated the fact that there still isn't an official medical term for vaginal secretions. I'm not talking about slang. There's plenty of that, from "smegma" (sounds like Gollum's sister) to "honey" (nice, but not unique). I mean an unambiguous, descriptive, neutral word of it's own. Like "semen". That's a word that can't be mistaken for anything else. It only has one meaning, as far as I know. It's only a noun, and calls up a distinctive mental picture. Nobody gets confused about what you're talking about when you say "semen."
But what is the "female version" of "semen"? The closest I can come up with is "discharge." But this does not meet the criteria of specificity that "semen" does. No, "discharge" is a word that can be a noun or a verb, can apply to a vagina, a retiring serviceman, or a firing cannon. Not only that, I was taught in medical school that a vaginal discharge is abnormal. Part of the Patient Interview is called the Review of Systems. When you do this, you verbally list the body systems, asking if there are any abnormal symptoms in each. (headache, double vision, vomiting blood, etc.) One of the questions is, "Do you have any vaginal discharge?" This is usually asked while shaking one's head and frowning slightly, subliminally communicating the right answer to the patient. Oh, no, ma'am. No vaginal discharge. Yuck, no!
Whereas in truth, feminine secretions are as normal as tears or saliva, or mucus.
I submit that we need a new word. A unique word for the entirely normal, benign, useful secretions that are produced in the vagina. What shall it be? We could call it "vuliva" (vuh-lye-vuh) or "vugucus" (vuh-joo-kus) , echoes of its cousins at the "other end. " We could even stoop to "vovey goo", although that doesn't sound quite neutral to me. Or, come to think of it, we could have several words. The stuff changes, you know, throughout a woman's monthly cycle and lifetime. The eskimos have their myriad words for "snow". The male urethra has four separate words for one little tubule. Why shouldn't there be a different word for each variety of hormonally-influenced natural feminine product?
The devil is in the details. I can't think of a good word. I just know we need one. I'm open to suggestions. Once we get a good one, we can submit it to the American Board of New Anatomical Terminology, or wherever one submits these things. Then all we'll need is for Eve Ensler to say it 128 times a night for six years, and voila! Equal time in the anatomy lectures, and a new addition to the church potluck repertoire.
Saturday, April 01, 2006
- Showing uses data from the five senses. Telling uses interpretive data. (e.g. showing = "his face was flaming red" and telling = "he was angry")
- Be specific in your nouns and adjectives for better description. (e.g. "he was built like a linebacker" instead of "he was big")
- Make your similes and metaphors as original as possible. One technique is to relate your metaphor to your story. (e.g. if food figures large in your story, use food metaphors - "his skin was like a lemon peel")
- For intense action scenes, slow down the writing, draw it out moment by moment to increase the tension. Using short paragraphs can give a sense of speed while you're doing this.
- For each detail you're considering using in your writing, ask yourself:
- Does it make the story more believable?
- Does it help readers picture or understand a character or place better?
- Does it answer questions that readers might want answered?
- Does it distract from the action?
- Could it be removed without confusing readers or weakening the story?
She had us do a number of quick writing exercises, where she'd give us a task and we had three minutes to write, then we'd share and comment. This was tough! Good practice, though. For your entertainment, here are a couple samples.
Instruction: Write about an alcohol beverage from the point of view of an alcoholic.
Peg's effort: "Congratulations!" they all yelled as the cork exploded out of the bottle. Angus alone was silent, transfixed by the bubbling cascade that foamed golden over Marty's wrist and puddled on the tablecloth. He moved closer, his nostrils flaring as he inhaled the call of liquid magic. Closer, and he unconsciously reached a finger out to caress the dampened linen. Closer, and finally he thrust his glass into the stream.
Instruction: Write about the same beverage from the point of view of someone who drank too much of it the night before.
Peg's effort: "Ohhh. Turn off the light!" moaned Shirley, rolling away from the window. "Eeyew- shit!" Her voice was louder now as she sat up suddenly, wiping old vomit off her cheek. "Oww, my head!"
Jack regarded this episode with a smirk. Rising from his stool, he grabbed a half-empty bottle of champagne from the coffee table and waved it under Shirley's face. "Here! Hair of the dog!"
Shirley paled, lurched, and vomited afresh.