Triple whammy

[nightengalesknd]

There are problems with medical training, philosophical and practical, too numerous to list, and I have journaled extensively about being victimized by many of them. Starting my fellowship, I will still be a medical trainee, but will also be a few rungs farther on the hierarchy of those who teach the trainees. On an academic level, I’ve become interested in how health care providers are trained to think about disability and chronic illness, both through official curricular components, and through the often damaging “hidden curriculum.” I’d like to work on the general issue of attitudes about disability among physicians and other providers, which is a big problem and one which may well be my research direction of a lifetime. As a smaller, but related problem, I’ve begun to think about the way medical students and interns, especially, are trained to conceptualize disability during a clinical encounter, and to see if there are ways to help develop an approach that will lead to better understanding for the trainee, and better care for the patient. And in thinking about how residents, even the best meaning residents build their knowledge and attitudes about chronic conditions, I've realized just how well designed the system is to create three related problems.

It was noted years ago that pediatrics residents train disproportionately in hospital settings, while most practicing pediatricians have office based practice and care for many healthy children. Gradually, some improvements have been made. Residents are required to have continuity clinic, a minimum of half a day each week, to learn to provide ongoing primary outpatient care. A community month was required in my program, and I think most if not all other programs, where residents visit anything from private practice pediatrics to school nurses to early intervention therapies. We also spent a month each year in the acute care clinic. But most of the required months, the so-called “service” months are inpatient, a fair bit of that in one of the ICUs, and most of the outpatient or mixed months are done as electives, so not everyone does the same ones. This means that, barring weird strokes of fate (such as my appendicitis jinx), the inpatient experiences are more similar than the outpatient ones. Everyone takes care of kids with congenital heart defects in the PICU, but not everyone does a month of cardiology. Everyone takes care of kids with cystic fibrosis on the floor, but not everyone does an elective in pulmonology or infectious disease, which jointly run the CF clinic. Everyone takes care of kids with spina bifida following shunt and tethered cord surgeries, but SB clinic isn’t part of any regular elective, and I had to carefully carve out time for it from other things. So for many chronic conditions of childhood, a resident’s only exposure may be in the inpatient setting. And as in other settings, the hidden message is that experiences which are required are those which are the most important.

This means a couple of things. In most cases, it means seeing a kid at his or her sickest. Some surgical admissions may be scheduled on a somewhat elective basis. For example, tethered cord releases and some heart operations may wait until school vacation in older kids. But the resident doesn’t generally meet those kids until after they come up from the OR, so even if they weren’t acutely ill before the operation, it’s safe to bet they aren’t at their stellar best immediately afterwards. And most kids with chronic conditions are hospitalized only when things get bad. An asthma exacerbation which can’t be treated at home, the pediatricians office or the ER. A CF exacerbation that failed to improve with oral antibiotics. A kid in diabetic ketoacidosis. An increase in seizure activity in a kid who is on five seizure medications already.

So the resident only gets to know kids with these conditions at a time when they land in the hospital. Sometimes the kids are acting sick and miserable. Sometimes, especially closer to discharge, they are acting less sick, although possibly more miserable. We send kids home with IV antibiotics a lot these days, so kids with CF who once might have stayed for two weeks, at which time they were likely to be feeling at their best, are now going home after a few days. Kids in DKA go to the PICU, and are generally acting sick at first, and grumpily hungry later. Kids following tethered cord repairs are required to lie flat for 72 hours, which is a sure recipe for boredom. It’s a rare kid who is truly happy and excited about being in the hospital. Which is completely understandable, but working mainly with kids with chronic illnesses when they are hospitalized means that some amount of nuance and understanding get missed.

The resident gets very good at calculating fluid needs of kids in DKA, without learning how children and their parents calculate carbohydrate content of typical meals and snacks. The resident becomes conditioned to think of a patient following spinal surgery as needing bedrest, without understanding the varied methods of mobility used by children with these conditions the rest of their lives. I’ve seen interns order “bedrest” as a default activity order for children with some disabilities because they “can’t walk.” I’ve seen this look of enlightenment dawn when I’ve explained that if there is no medical reason for bedrest, the child would be able to go to the playroom using a wheelchair or take a wagon ride out to the fish tank.

I read a study a few years back which surveyed several pediatric specialties about if they would ever recommend home ventilator use for kids with SMA, a form of muscular dystrophy which can affect respiration in young children. None of the PICU doctors ever did, but some of the neurologists and a lot of the rehab doctors did. The authors suggested that the PICU doctors only had a sense of this condition when it brought kids into their ICU, in crisis. Meanwhile, the rehab doctors, especially, knew the kids and families through a series of outpatient visits, through good times and bad, and had a better sense of life outside the hospital for the child and family. Few medical students or residents learn about the realities of life on the outside for people with SMA, or CP, or living with a mobility impairment in general.

I remember seeing a kid who had CP in a specialty clinic for a completely unrelated condition, and mentioning in the workroom that he was playing baseball. Then I explained Miracle League baseball to the chorus of confused students and other residents. We are taught that CP = wheelchair and CP = seizures and CP = sick, but not that CP can also = baseball.

So that’s whammy number one, mainly seeing chronic illness at times of acute crisis.

Second, the kids with chronic conditions which are hospitalized the most frequently tend to be the kids with the more severe or difficult to manage version of any given condition. Most kids with asthma do not end up hospitalized with exacerbations. Many kids with diabetes don’t go into DKA after initial diagnosis and get admitted two or three times a year. Many kids with CF are hospitalized rarely. Most kids with cerebral palsy aren’t more prone to repeated pneumonias than kids with CP. But there’s a few kids with significant motor impairment who do get admitted with frequent, serious respiratory infections, and these are also usually the kids with significant cognitive disabilities. It would be very easy for a resident with no other exposure to kids with CP to start to see the abilities of these few kids as representative of all people with the condition. Some kids with shunts can go through childhood without any failures requiring revision, while a few seem to need one revision or replacement after another. And so on. Pick a condition with a spectrum of presentation, and there will be a small percentage who need much more frequent and intense medical care than most of the other kids with the same condition.

For a resident to see the spectrum, they would need to do a clinic based elective. Spend a month in endocrine clinic and see all the kids with diabetes who may not have ideal control, but don’t go into DKA over and over and over. (Of course, most of the kids who go into DKA over and over don’t show up for their scheduled visits in clinic.) Spend a month in ID and see the kids with CF who have the gene mutations associated with less significant lung damage. Spend a month in ID clinic and see adults living with CF, some of whom are even grandparents. Spending a month in neurology clinic doesn’t guarantee seeing kids with CP who are generally well, since most kids with CP don’t see a neurologist regularly. You do see kids with CP who also have seizures, and you do learn a lot about seizures, but not so much about CP. You are taught to ask if the kid is getting special ed services, and any other therapies, and that’s it. You aren’t taught what to do or think about the answers.
That’s the second whammy.

And both those whammys have been known and discussed among the medical academians for some time, and with some improvement over the past 30 years or so. Like I said earlier, at least we have clinic months. What I haven’t seen mentioned is the third factor.

In many, although of course by no means, all cases, the kids with any given condition who end up frequently in the hospital are the kids with more difficulty keeping up with the home care aspects of the condition. This means that they tend to be the kids with more family issues and less structure at home. Some parents are able to troubleshoot high blood sugars caused by illness or an insulin pump problem either at home or over the phone with their doctors. So the kids with recurrent DKA tend to belong to families with fewer problem solving skills. I recall one pre-teen whose mother struggled to remember the steps to refill the pump, and a teen who had become intoxicated at a party in his home. Both were admitted several times one year. I also recall a child who was not admitted, who was having high blood sugars since one of her parents, who split custody, got a kitten. The cat, see, was biting through her insulin pump tubing at night. Our medical recommendation: cat out of the bedroom at night. It’s a great illustration of the times we prescribe more common sense than state of the art medicine, and I tell it not to ridicule a family who clearly cared for their child, but to illustrate how parental problem solving ability can impact a child’s health.

Many of the kids with CF who are admitted frequently are the ones who are less able to keep up with recommended treatments at home, which usually translates into those whose parents are less able to keep up with recommended treatments. In addition to being hospitalized more often, these kids are less often candidates for home IV therapy. So the intern sees the family every day for two or three weeks, and gets a picture in his or her head about CF based on one “difficult” family due to the simple math of exposure. Two weeks can be a long time to follow a kid, especially one who doesn’t seem to be getting “better”.

And many of these families are the ones which tend to be labeled as difficult. There are often custody issues, sometimes messy ones. There may be CPS involvement. The parents may have mental health conditions. There may be issues of literacy, or health literacy, so the most vocal family member may have a concept of disease or treatment which is at odds with the traditional biomedical explanation. The family may be very particular on the timing and brand names used for medications, and seem world-weary because they have been here before, literally, even if the intern has not. Some of the parents are the ones termed “crazy” at resident sign out. It’s not a term I like, for many reasons, and so I don’t use it, but I do see how the frustration with a family can start to morph into ones feelings for a condition with which a trainee has no other background. Imagine taking care of a kid with a rare, complicated condition you have never heard of, and then imagine doing it knowing that you are going to be asked to spend half an hour you don’t have telling the kid’s mother the same things you told her yesterday and don’t quite understand, and then she’s going to yell at you. The ER calls, and you hear whose down there, and even the most caring resident is bound to say, “Again?”

Of course, families can be challenging in clinic, too. But outpatient visits are shorter and the attending is closer at hand. A problem at 2 PM can be handled by the attending, and the patient will likely have left by three. A non-life threatening problem at 2 AM is a resident problem, and the patient and family will still be there at 6, when the resident pre-rounds, and 9, during rounds, and noon when the resident is trying to leave post-call but the nurse says the grandmother just arrived and wants to talk to someone. The chances are pretty good the family will still be there the next morning, too.

So the face of chronic illness and disability can become the face of a frustrating encounter, the face of an irate parent, the face of a bitter custody dispute, in addition to being the face of a problem the resident cannot solve. And it’s often the face of “non-compliance,” another term which I hate. If the only patient with CF that an intern meets is a teen who doesn’t take her medication and won’t use her oxygen, it’s easy to see how a picture can develop of CF that includes not following medical recommendations. If the resident has admitted the same kid to the PICU for DKA twice already this month, and this kid sneaks food and doesn’t remember to take his insulin, it’s easy to see how that can become the picture, not just of this one kid in DKA, but of diabetes. Not every intern has a diabetic senior resident standing around as a counter example. One can start to think in generalities, that “they” don’t do this and “they all do that,” for patients with any given disease. And the people training the residents, the role models, by and large are products of the same system. So there may be messages from above that reinforce the frustration.

I don’t know how to fix it.

More clinic exposure may be part of the answer, but only part. Acknowledging the whammys may help, reminding medical students and interns about the spectrum of the condition and that their perception as an inpatient provider is skewed. Students tend to know facts about given conditions. Grab any second year student and ask about CF, and they can tell you all about the gene that is mutated and which infections are common. Ask about diabetes and learn about beta cell destruction and renal complications. But ask them about living with either chronic condition, about what it is like to have to think and do math before eating a single bite, about eating when you aren’t hungry? They haven’t been taught about that. Ask about spina bifida and learn about which week of gestation forms the spinal cord, about CP and get the textbook definition of spasticity. But they haven’t been taught anything about the realities of living with a motor impairment or about related feeding or vision issues. They haven’t been taught what questions to ask about physical therapy or mobility equipment.

So I think part of the answer is providing fewer facts about any given condition and a better framework overall. We need to find a way to teach students how to approach chronic illness and disability and develop appropriate questions. Most pediatric residents have a mental set of questions they ask at different ages, about diaper changes and feeding schedules in babies, school and bicycle helmets in the school agers, sex, drugs and rock and roll in the teens. They ask often, hear their mentors ask often, and have written templates reminding them at each visit. I’m thinking part of the answer is to create templates and provide modeling for questions and concepts which are relevant to many chronic conditions. Then we can work on knowing what to do with the answers.

Comments

[read2781.livejournal.com]

Wow, this is such a powerful entry! I had goosebumps reading it because, even though you spoke of pediatrics, your words are so true in the adult care model.

Take Dr. F. for example. He immediately said that he wanted to do an invasive surgery to fix my ankle problem. I had to prod him to even think about non operative management. Should I put MD after my name? Probably not, but on that day, I felt like I was the doctor, and he was some ignorant resident or intern. Let's also not forget when I asked him to write down the name of the procedures so I could research them. He looked at me like I was from Mars and then proceeded to ask "Where do you want me to write it?" In my brain, Doctor! Seriously! He had no concept!!

Another thing to consider is the pediatric doctor who treats a teenager like she is an infant. For example, I was 16 years old, roughly, and saw an orthopedic doctor. He was doing his assessment, and my ankle was not loosening up appropriately. He said, in this sing song voice, "Make your foot Lucy Goosey." I wanted to hurl something at him! I was soooo mortified! And then he proceeded to tell us the only way to treat the problem was a surgery, oh and by the way, let's not waste a moment because after a short amount of time, the surgery won't even be effective.

The other thing to consider is doctors, fellows, residents, etc. who are writing reports. I have seen doozies regarding my foot care for example. I;ll never forget this one guy's report from Shriners. Keep in mind, I was 19 years old at the time and a freshman or sophomore in college. The doctor's report said, and I quote," Patient is 19 months old and is experiencing significant developmental delays." What! Really? I couldn't believe it!

And let's not forget an ophthamologist who says "Sit in the chair over there." Clearly, I could not see where he was pointing, and when I explained this, which by the way I shouldn't have had to with my dog or cane present, he did not get it.

I could go on and on about this topic. If you need people to interview about experiences, I'm in!

[nightengalesknd.livejournal.com]

Adult medicine can be worse. I just don't have direct training experience in it. But my experience is that if pediatricians are poorly trained about disability, most adult doctors are even less so. Few of them know anything about cerebral palsy, and most of them don't know anything about type 1 diabetes either. The problem isn't finding out the experiences. The problem is figuring out how to help train people so it stops happening.

Part of it is something else I need to write about, the deficit model. The medical experts on a given condition are the ones trained to try to prevent or cure that condition. The orthopedists become the experts in mobility problems. The opthalmologists become the experts in eye problems. The ENTs become the experts in hearing problems. Except that they aren't really trained in how people live with any of these problems. Physical disability has the rehab doctors, but other disabilites don't really have anyone like that.

[kittenmommy.livejournal.com]

But my experience is that if pediatricians are poorly trained about disability, most adult doctors are even less so. Few of them know anything about cerebral palsy

You're not kidding! :p

[zdenka]

I always find these essays of yours interesting. It's definitely interesting what you say about how medical students don't have training/experience in thinking about what it's like to live with a condition on a daily basis.

I’ve seen interns order “bedrest” as a default activity order for children with some disabilities because they “can’t walk.”

That's frustrating and slightly horrifying.

And on "non-compliance" -- yeah, I've been non-compliant about taking medication a number of times in my life, and there was always a reason that made sense to me.

[nightengalesknd.livejournal.com]

There's generally a reason. I've been "non-compliant" myself. I usually ask people why they haven't taken their medication, and try to see if there's a solution. Sometimes there is and sometimes there isn't, but shrugging off certain patients as "non-compliant" pretty much seems guaranteed not to help either the patient or the doctor.

[aries11.livejournal.com]

When you write these entries, I always think about how good a doctor you're going to be. You see EVERYTHING that there is to see in your field, and you even look a little deeper than your peers do at times. You actually give me faith in the future of the medical system, to know there will be someone out there who genuinely cares as much as you do.

[nightengalesknd.livejournal.com]

Aw, thanks.

A lot of doctors are actually well meaning and caring people, who are shaped by the system without realizing there's often another perspective. And since the other perspective affects so many of our patients. . .

[lilituc.livejournal.com]

How interesting - I've heard so many stories from people who took their sick kid to a pediatrician and was told, "it can't be _____ or they would be a lot sicker." But it turned out to be _____. Especially with Type 1.

This explains a lot.

[nightengalesknd.livejournal.com]

And I'm thinking about what tends to happen to otherwise well meaning and caring doctors simply due to experience and exposure. It gets magnified if the person already is some sort of know-it-all.

Missing diabetes is especially silly, though. Fingersticks and urine tests on little kids aren't exactly fun, but they are fast, available and cheap.

[songblaze.livejournal.com]

Happens when you develop a disability as an adult. My otherwise competent GP was certain I didn't have EDS because I didn't have 'the look' (there are what, 7 types of EDS and only 1 type has this characteristic look, and even then it doesn't always have it) and because I 'wasn't severe enough'. I pushed her and got the consult with a geneticist and sure enough, I got the dx.

[nightengalesknd.livejournal.com]

Yah. Of course, I'm the one who got diagnosed with CP, a childhood condition, at 28. . .

[kindletheflame.livejournal.com]

As usual, excellent post. Although I only skimmed, because I'm on my way out to work; I'll have to take a real read when I get home.

There's a teacher at my school who has had CF for something like 45 years (and also has diabetes—she was asking me about the pump) and seems to manage just fine. Even I, someone with a disability and chronic illness, who had until then never met someone with CF and only knew what was in books and on TV, had to stop myself from thinking, "Wow, she's not sick all the time?" The difference, perhaps, is that I actually consciously caught myself thinking this and was able to stop.

[nightengalesknd.livejournal.com]

And the other difference being that it's not in your job description to supposedly know all about her condition and help her take care of it.

[kittenmommy.livejournal.com]

I also recall a child who was not admitted, who was having high blood sugars since one of her parents, who split custody, got a kitten. The cat, see, was biting through her insulin pump tubing at night.

This doesn't surprise me. The cat probably thought that the pump didn't belong/was harming the child.

When I had my heel cord release at age 10, my cat would sit on my leg and try to remove the cast (by licking it, LOL). I even have a picture somewhere of me asleep, with the cat going at my cast like crazy trying to remove that offensive foreign body that was clearly harming me in some way.

And it’s often the face of “non-compliance,” another term which I hate. If the only patient with CF that an intern meets is a teen who doesn’t take her medication and won’t use her oxygen, it’s easy to see how a picture can develop of CF that includes not following medical recommendations.

My doctor gave me this horrible new blood pressure medication that caused unbelievable stomach cramps. I complained, and he said it was in my imagination. I complained, and he told me to take Gas-X. I called the pharmacist, and she confirmed that stomach cramps were a very rare but possible side effect. I called my doctor's office and said I wasn't going to take it anymore, and he had to give me something else. He refused. I told him again that I was quitting the med and going back to the old one (I still had some pills left).

After about a week of this, he gave in and put me on something else. But seriously, how hard is it to listen to a patient's experience and do something about it?

This is the "you can't have CP guy because you're not profoundly retarded and in a wheelchair", BTW. In case you were wondering.

[nightengalesknd.livejournal.com]

I'm not surprised at the action of the cat. Tubing is pretty much a piece of string, after all. I was a bit disapointed at the action of the adult human, however. After the second occurance, one would think the parent would take steps to separate the two overnight.

I find it easy to listen to a patient's experience and sometimes easy to do something about it. There are medications that have more options than others. There are lots of blood pressure medications out there, and also, stopping one doesn't generally have short term consequences. There are fewer ways to take insulin, and stopping it can have very immediate short term consequences. So "I don't like the way my blood pressure pill makes me feel" and "I don't like taking insulin" may need different responses. But either way, I can at least listen to the problem.

And it's good to know you didn't have CP in addition to high blood pressure!

[kittenmommy.livejournal.com]

I'm not surprised at the action of the cat. Tubing is pretty much a piece of string, after all.

Hmm, I hadn't thought of it from that angle, that the cat might've been playing with a cool new toy. That's always possible, too.

I was a bit disapointed at the action of the adult human, however. After the second occurance, one would think the parent would take steps to separate the two overnight.

One would think so, but... yeah. Common sense FAIL.

I find it easy to listen to a patient's experience and sometimes easy to do something about it.

I wish you were my doctor!

There are medications that have more options than others. There are lots of blood pressure medications out there, and also, stopping one doesn't generally have short term consequences. There are fewer ways to take insulin, and stopping it can have very immediate short term consequences. So "I don't like the way my blood pressure pill makes me feel" and "I don't like taking insulin" may need different responses. But either way, I can at least listen to the problem.

Oh, I totally agree that BP meds < insulin! I was just using that as an example of "Ha ha, we can't hear you, don't believe you, don't care, so shut up and take Med X even though it makes you miserable!".

And it's good to know you didn't have CP in addition to high blood pressure!

I must not have high blood pressure anymore, because now he's telling me to eat lots and lots of salt. In addition to taking the BP meds. Yeah, IDK either. I'm starting to think this guy got his license out of a gumball machine.

[nightengalesknd.livejournal.com]

You're cured!

I wish I could get my license out of a gumball machine. My current application process for the state I'm moving to includes a criminal background check (got fingerprinted at the local PD and mailed off the fingerprints along with a photocopy of my drivers license and social security card), obtaining a certified copy of my birth certificate (photocopy of the original not acceptable), three letters of recommendation from physicians written on letterhead, and a $300+ identify verfication process that includes asking an agency to release my test scores to itself for $65.

This is not to mention the requirement that I write, "in my own handwriting" why I want to be a physician in that state. Although I am physically capable of handwriting a few sentences, as a person with a handwriting disability I find that requirement discriminatory. Inability to handwrite does not proclude the practice of medicine, but it's not as though I have the resources to go fight city hall on that one.

There's a gumball machine at Friendlys, come to think of it. . .

[kindletheflame.livejournal.com]

This is not to mention the requirement that I write, "in my own handwriting" why I want to be a physician in that state.

As a person with a visual impairment I also find that discriminatory. But then, if I ever wanted to become a doctor I'd probably have bigger battles to fight, like actually getting people to believe it was possible.

It's like job postings that list "driver's license" as a requirement even though driving is not an essential part of the job. Usually travelling is an essential part, and the people writing the aplication just can't fathom that there must be any other ways of getting around besides a car.

[nightengalesknd.livejournal.com]

Yeah, I thought of VI as another condition for which this requirement seems discriminatory. There are blind doctors and doctors with less hand use than I have. They aren't surgeons, but getting a medical license in a given state doesn't mean one can automatically be a surgeon. They do ask questions on the application about if you have a physical or mental condition that limits your ability to practice in any way, which I think is a legal and appropriate question.

And a drivers license is required for this application as well for identification purposes, without stating it will accept a state issued non-driver's license. Grr all around.

[songblaze.livejournal.com]

Resources - is it legal resources or emotional/physical/time resources you do not have? If it's the latter, I'd be happy to put you in contact with someone. If it's the former, I totally understand and sympathize.

[nightengalesknd.livejournal.com]

Emotional and time. The application process is already lengthy enough that the last thing I need is to prolong the process. And since I am able to meet the requirement, I suspect I would have less of a legal leg to stand on. However, after I get the thing and move to SC, I will try to make some calls and see if there's anything I can do about it.

Does it seem legal to you, at first pass, to require a handwritten statement to obtain a medical license?

[songblaze.livejournal.com]

Absolutely not. No way.

Hmm. The fact that you have increased difficulty meeting the requirement because of a disability may be enough.

[nightengalesknd.livejournal.com]

You think? Not to argue with your legal opinion of course. . .

But it's one thing when I was taking, say, the MCAT, where increased difficulty with handwriting could have meant an illegible answer, not enough time to finish, an unfair failing score, because there was a time crunch, and another for something that might take me an hour instead of ten minutes, but there's no time limit and the end result is legible.

[kittenmommy.livejournal.com]

You're cured!

Yay! *throws away BP meds and pours salt on everything in sight*

I wish I could get my license out of a gumball machine. My current application process for the state I'm moving to includes a criminal background check (got fingerprinted at the local PD and mailed off the fingerprints along with a photocopy of my drivers license and social security card), obtaining a certified copy of my birth certificate (photocopy of the original not acceptable), three letters of recommendation from physicians written on letterhead

So, not at all complicated and inconvenient, then.

and a $300+ identify verfication process that includes asking an agency to release my test scores to itself for $65.

What is this I don't even

This is not to mention the requirement that I write, "in my own handwriting" why I want to be a physician in that state.

Ah hahahahah!

Sorry. It's just that I remember your posts re: your handwriting.

Although I am physically capable of handwriting a few sentences, as a person with a handwriting disability I find that requirement discriminatory.

Does it all have to be done in one shot, or could you do it in increments? You know, write a little, put it down, come back and write more, wash and repeat until finished.

Inability to handwrite does not proclude the practice of medicine,

If it were, my uncle would've lost his license ages ago. I think I told you about that time he sent me a birthday card and it got returned to him because they couldn't read my address! The only reason they knew his return address was he sent it in a pre-stamped envelope from his office, LOL.

Doctors having awful handwriting is such a cliché, but in some cases it's really true. And vets also have appalling handwriting, for most of the same reasons, probably.

but it's not as though I have the resources to go fight city hall on that one.

There's a gumball machine at Friendlys, come to think of it. . .

It'll only cost you a quarter, too! :D

[nightengalesknd.livejournal.com]

I forgot to mention, as far as not being inconvenient or complicated or anything, that the form also asks for my congressional district. Of course, I don't even yet live in the state for which I am requesting a license, so I'm not sure what a southern state is going to do with my New England state congressional district. Or what they would have done with my in-state district in the first place. Besides, they have my address so can't they just look it up?

I'm filling out the application at home, so the statement can be done over time, and that is what I plan to do. I've pretty much decided what I want to say and distilled it down to a reasonabally succinct sentence which I will type out onto my computer and then handcopy onto the form. But the fact that I can do it doesn't mean that I think it's a fair or legal requirement.

[kittenmommy.livejournal.com]

I forgot to mention, as far as not being inconvenient or complicated or anything, that the form also asks for my congressional district. Of course, I don't even yet live in the state for which I am requesting a license, so I'm not sure what a southern state is going to do with my New England state congressional district. Or what they would have done with my in-state district in the first place. Besides, they have my address so can't they just look it up?

Oh God, they inspire such confidence! I mean, these people are (I assume) also licensed to practice medicine? That's terrifying, since they don't seem to have much sense!

I'm filling out the application at home, so the statement can be done over time, and that is what I plan to do. I've pretty much decided what I want to say and distilled it down to a reasonabally succinct sentence which I will type out onto my computer and then handcopy onto the form.

Excellent!

But the fact that I can do it doesn't mean that I think it's a fair or legal requirement.

I agree! The time to fight it probably isn't now, though, when you're trying to get them to give you a license! Though later... *evil grin*

[nightengalesknd.livejournal.com]

I think either people with common sense are not promoted to their state board of medical examiners, or they are required to relinquish any residual sense at the time of appointment. (Or the forms are designed by non-physician beaurocrats.)

[kittenmommy.livejournal.com]

Any/all of those explanations work!

[ericaceous.livejournal.com]

this is great, great, great.

[nightengalesknd.livejournal.com]

Aw, thanks!

[nightengalesknd.livejournal.com]

You and me, both. Conventional wisdom is that I can't have CP, since I'm verbal and ambulatory. I saw a neurologist at 8 and one at 22 who both missed it. I only saw one at 28 to get diagnosed and to write letters to people saying they had to let me type stuff. There's no reason to keep seeing a neurologist if there's no need for ongoing treatment. What are they going to do, recheck our muscles and reflexes and say, "yup, still CP?"

Doctors are notoriously bad at dealing with people who have multiple unrelated medical issues. They aren't taught to think that way. Test questions always make the patient "otherwise healthy" or gives relevant other diseases, never random unrelated ones, which just reinforces the problem. My last PCP became such when I had a sick visit with him for a respiratory infection. I was so impressed he was able to take in my chronic stuff, set aside what was irrelevant (like CP), keep in mind what was relevant (diabetes, asthma) and focus on the acute problem. He and I were both interns at the time. But that's one in a million. I hope he goes into practice somewhere that he can teach.

[songblaze.livejournal.com]

My GP is the same. When I come in, after we talk about whatever I came in for, he does often ask how the chronic stuff is doing just because he keeps tabs on everything like that, but during the main discussion of the appointment, my chronic stuff is only included if it might be relevant.

I very much hope he teaches someday, because he's the most patient-centered GP I've ever had. If he can pass THAT on to the next generation of doctors, maybe we'll have a few more doctors who can treat us like human beings instead of walking disorders and diseases. Right now, I know he has supervised med students, so I assume he's got some sort of teaching responsibilities.

[nightengalesknd.livejournal.com]

He is. Very similar, come to think of it. And he does teach both students and residents in his current practice, not by classroom lectures but by example.

The thing is, though, I think he's innately good at it. And the fact that my FP was so good as an intern makes me think that he's innately good as well.

What I'm trying to figure out is how those of us who are good at chronic illness and disability management do the parts that don't depend on innate ability, so that we can teach it to those who don't have either the instinct or the background. If people who don't have that inherent ability can be taught better skills, then they will become more comfortable in these situations and ultimately give better care. And you can't teach instinct. I guess what I really need to do is find people who learned how to do this stuff, and ask what they learned and how it was taught to them. . .

[chem-nerd.livejournal.com]

This makes perfect sense. And it's weird how even the littlest things can slip people's notice. I'm allergic to a couple of different classes of antibiotics, including the penicillin family, but I can take cephalosporins okay. There's a 3% chance of cross-reaction in patients with penicillin allregies, but I'm in the other 97%. The local Target pharmacist has earned my infinite respect for being the first person ever to warn me about the potential cross-reaction when she filled the scrip. Being a bibliophile with an interest in all things scientific or medicinal, I did happen to already know about it, but she was the first pharmacist to ever check and make ZSURE that I knew about it. (To her credit, the doc did ask if I could take Cefzil before she wrote the scrip).

On an unrelated note: have you ever heard of azithromyacin being prescribed for less than 5 days? Doc just wrote me a five day scrip, but when I got to the pharmacy, my insurance would only cover four...

[nightengalesknd.livejournal.com]

I've heard of a one day/one dose of 1000mg being given for certain STDs, but aside from that, no. In adult sized people it's usually a 500mg loading dose the first day, followed by 250mg for the subsequent 4 days. The packet usually contains six 250mg tablets For recalcitrant sinus infections, I've seen that followed by 5 days off and another five day run. I can't think of any 4 day protocols. If you can get ahold of a human at your insurance company, ask them what the 4 day protocol is meant to treat. . .

[chem-nerd.livejournal.com]

I'm going to have to do that, I think. I went ahead and had them just give me the fifth tablet and paid for it out of pocket - given that this is treating what's left of a sinus infection that cefzil didn't get, and cefzil and zithromax are the only two commonly prescribed antibiotics I can take, I DON'T want this sucker going resistant on me. This isn't even the sixth tablet loading dose - the scrip was written for 5 tablets, my insurance would only cover four. And I realize that they have to save costs here and there - I'm fine with their substituting generics when available. When they wouldn't cover one steroid nasal spray for my allergies, I was fine with my doc substituting a similar, older drug that had a generic. But azithromyacin IS the generic. When did insurance buroucracy override medical knowledge. Don't they realize that if they create drug-resistant bacteria by short-changing people on antibiotics, that will cost a hell of a lot more to treat?

[nightengalesknd.livejournal.com]

I have it on reasonable authority that there are people with actual medical training working for insurance companies.

I've yet to meet or speak with any.

I think they have some medical committee type people somewhere, who make up the rules based on how they think the world should work, or worked once, somewhere, and then everyone else points to those rules when individuals speak up about how the world isn't working that way for them. I've seen insurance companies authorize lengthy hospital stays, but not medications or equipment or home nursing that, while expensive, might have prevented or at least shortened the admission.

There are people in the hospital, nurses, mostly, whose entire job consists of trying to get things approved and authorized and arranged. One of these care managers and I considered buying a kid a ventilator off E-bay, at one point. (Yes, they have ventilators. And no, we didn't do it.) And I always joke that I rather enjoy yelling at patient insurance companies as a nice change from yelling at my own.

[chem-nerd.livejournal.com]

What really scares me is... My employer has a good health plan, it's an advantage of working for a large corporation. My husband and I don't have to think twice about going to the doctor when we're sick. Much as I complained about the bills when I needed emergency surgery a year ago, the fact is, insurance covered about 80% of it. And I'm in a position to say, 'yeah, just give me the fifth one, and I'll pay for it.' But I have coworkers with the same insurance policy I have in positions with lower pay grades who are trying to raise families and are pinching pennies - if one of their kids were sick, could they afford to pay the $13.50 for the one azithromyacin tablet that our coverage overrides on the scrip? Should they have to? And don't even get me started on the millions of poor souls who are trying to get by in this country with no coverage at all...

[nightengalesknd.livejournal.com]

I know. And kids tend to take liquid suspensions, which cost more. . . I took care of a kid who was hospitalized for IV antibiotics because her insurance wouldn't cover the oral one we prescribed and it cost over $100 so her family couldn't afford it. They did give her a cheaper antibiotic but it didn't cover her infection. But hey, they covered her two day hospital stay, which I bet cost more than $100. And she's one of the lucky ones who had insurance. . .