I started this site when I was working as a nurse practitioner at a community health center. I stepped back from a clinical role almost a year ago and while I still have many tales to tell, was not motivated to write about them. Until now. No, it’s not about the recent election. This is an issue that predates that by at least 10 years.
The clinic is broken. Well, health care is broken, especially when it comes to primary care. And I don’t know who is more unhappy about that, patients or providers. I can’t speak for doctors, but I can speak about what my fellow nurse practitioners tell me.
It doesn’t matter if you work at a community health center, one of the new, streamlined, tech-driven companies such as One Medical or Forward, or a private medical practice, whether or not is now owned by a hedge fund. Although, at least in the New York Metro area, it seems that most of them are.
You might wonder why non-profits push nurse practitioners to see more patients. In the case of community health centers, the push comes from meeting quotas to get or maintain grants, and the need to bring in enough money to keep the place open. Since no one is turned away, unpaid visits have to be made up for by paid visits.
Wherever they work in primary care, nurse practitioners are stretched, pushed and pulled to see more patients. Complicated patients. Patients who in some cases, should be seeing an MD. Patients who deserve more than a 15-minute visit (which, by the way, is every patient). Many nurse practitioners are not receiving a fraction of the support doctors do. And many do not have the support of doctors who are also too harried to answer questions or consult on a patient. And while it’s not just about the money, it is worth noting nurse practitioners make a fraction of what doctors do but are expected to carry the same caseload.
None of my nurse practitioner friends are happy in their jobs. Is it being a mid-level provider that’s the problem, or is it primary care? Being in a specialty seems a better option but my friends are concerned about losing their skills, about doing basically just one thing, as they see it, if they worked in a specialty. And they would miss their patients. They went to school, sacrificed, so they could become primary care providers. And they are needed more than ever, and not just in rural or poverty-stricken areas.
So what is the solution? Increased staffing would help, but it has to be more thoughtful than that. Most of the NPs I know prefer working collegially with doctors who are on site. Like all providers, including doctors, they would like more time per patient visit. And they would prefer to leave the medically complicated patients to the doctors who were trained to take care of them.
But where is the money to finance such a scenario going to come from? Certainly not the hedge funds, who are buying up practices and hospitals because they think, without knowing anything about health care, they can make practices and hospitals more profitable. They “do it better” by squeezing the most productivity they can out of providers. The result has been a mass exodus of providers in private primary care. In many cases, these providers (mostly doctors) go to concierge medicine, leaving the mid-level providers, the NPS and Pas, to pick up the slack. Until, of course, they are too burned out to do so. It’s a sad, dangerous situation. I wish I had a better tale from the clinic. Until I do. I’m signing off.
Even when I am not “working” as an NP, friends and family still solicit my advice. That’s no problem. I can’t stop thinking like a nurse practitioner, keeping up with new advances in health care or wanting to help people negotiate our health care system, which is broken, in so many ways.
What advice do I give? Sometimes it’s a matter of using the right lingo, even some key words, emphasizing one symptom, and being persistent. It also helps to put yourself in the shoes of your health care provider. NPs, MDs, PAs, we all want to solve your problem. We love a mystery, and most of us really care about making you feel better. So if you finally get an appointment and describe your problem — back pain, say — the assumption is that you want it to stop, at all costs. But is that really the case?
Maybe you can put up with the pain. It’s not that bad really and gets better as the day goes on. But you want to make sure the pain is not caused by anything serious, and rightly so. A malignancy is always in the back of one’s mind, as well as that of your provider. Or maybe it’s something that, if not treated, is sure to get much worse. You don’t want that either. Providers get 15 minutes a visit, if they are lucky, and they have a lot of mandatory charting to do on the computer. You have to distill your symptoms and your concerns and communicate them succinctly. That is just the way it is these days.
Perhaps the next step is some kind of imaging, an ultrasound, Xray or MRI. The radiologist who reads the image is likely overworked and usually errs on the side of caution. So further imaging might be suggested to rule out “something bad.” MRIs and ultrasounds are fairly benign in that they don’t expose you to radiation. CT scans do and the exposure is cumulative over a lifetime. What you decide to do is dictated at times by the level of uncertainly you are willing to live with.
Sadly, this can be a slippery slope. You then see an orthopedist who tells you your pain is caused by a benign cyst pressing against a nerve on your spinal cord. You could get it removed or injected with a steroid, which might alleviate pain or cause it to “pop.” The orthopedist gives you these options because you consulted her about your pain so obviously you want her to make it go away. Now you are on to invasive procedures and invasive procedures, every one, has the potential of making things much much worse.
Always ask what happens if you do nothing. Might it get better on its own? Might it just stay the same? Consider if you can live with this new normal. And of course, there is always a second opinion.
Case in point: I am a runner and developed arthritis in one foot that caused significant pain after, but not during, a run. I consulted an orthopedist who was touted as being a runner who specialized in foot problems to see if there was any recourse. Orthotics, joint replacement, I was open to hearing about options. I was concerned it would get worse and prevent me from running. First red flag was when he was surprised at how far I ran – 6-8 miles. He was a runner, after all, that distance should not have surprised him. Then he suggested a little surgery to “clean the area up.” There is not such thing as “a little surgery,” but I had already written him off by then. I sought out another orthopedist specializing in feet, who looked at the Xray, did a quick exam and said he would never operate on me because, although only a surgical fusion would relieve the pain, I would no longer be able to run afterwards. He suggested a steel orthotic available on Amazon. Six years later, I am still using it and still running.
In the arsenal used to fight COVID, there’s no doubt that vaccines are the non-human heroes of the pandemic. A close second, though, is the once lowly, often stuffed-in-a-provider’s-desk-drawer, N95 mask. Before the pandemic, not a lot of people outside of healthcare were familiar with it. We healthcare providers kept our own N95s stored in a paper bag with our names scrawled on it, out of sight and usually out of mind. These masks had one sole purpose — to protect us from tuberculosis (TB) if we took care of a patient who had active TB.
We were “fit-tested” once a year to make sure the mask would function. The fit test was basically, well, weird. You donned your N95 mask and the occupational health nurse would put a kind of plastic dome over your head. Then they sprayed a chemical with a sickly-sweet floral fragrance under the hood. If you could not smell it, you were good. If you could, you needed a new, better fitting mask. And, we were cautioned, once the mask was used, particularly in a verified TB situation, it was to be thrown out. It was contaminated and should not be used again.
For lack of a more nuanced reaction to this bit of history — Ha. COVID made the lowly N95 mask a superstar, elusive and sought after. Everyone wanted one. There were dire shortages. People were stealing them and they had to be kept under lock and key. And now apparently they could be used countless times even after contact with infected people. Just like that. And we found that a properly fitting N95 was a very uncomfortable thing to wear all day.
But this post isn’t really about the N95. It’s about public health and the role it still plays in mitigating another highly contagious disease in the community, the eroding concept of the common good, and vaccine hesitancy.
In the time before many vaccines were available, there were numerous outbreaks of dangerous diseases. Typhoid, diphtheria and polio come to mind. Health departments enforced quarantines, complete with signs nailed to front doors. No one questioned this because it was so obviously for the common good. No one wanted themselves or their families to become sick and die.
Tuberculosis, while not as virulent or as lethal as the aforementioned diseases, was a bane nonetheless. Many people died of TB, including two of my grandparents, in the first part of the 20ieth century. It was generally a disease that attacked people in poor health, living in crowded conditions, which then as now, unfortunately goes hand in hand with poverty. TB is just as contagious as COVID but here’s the big difference. Most healthy people exposed will develop latent tuberculosis infection or LTBI, which does not make you sick or contagious. It will however, make a TB test positive, because the dormant bacterium that causes TB (mycobacterium tuberculosis) is still detectable, even though your immune system has walled it off and made it inactive.
To this day, healthcare providers are tested once a year for TB. If the test is positive, it signifies exposure but not necessarily active disease. The next step after a positive test is a chest x-ray which would detect active, and thereby contagious disease. I have known many providers who were exposed, some knew it, some didn’t, and their tests were positive, and remain so. There is a treatment regimen advised for people with LTBI. The reasoning is that that the disease lies dormant until the host weakens, whether from illness, old age or even pregnancy, and then reactivates, becoming a contagious and potentially fatal disease. The treatment for LTBI consists of daily meds for a few months and some of the medications are not well tolerated. If you are deemed young enough and well enough to take the regimen (some of the meds could be toxic to the liver), it is advised to do so in order to prevent reactivation in the future. While the incidence of tuberculosis has decreased in this country, the advent of HIV/AIDS produced drug resistant strains, which requires more discussion than feasible in this post.
You might ask why I’m discussing tuberculosis at all when we are still in the midst of a pandemic of a much more dangerous disease. It has to do with my commitment to public health and my struggle to understand COVID vaccine hesitancy and anti-maskers. Public health authorities were instrumental to and successful at controlling TB. And most people were grateful for it, which is so very different from what is happening today amidst a battle with much more dire consequences if lost.
There was a thought-provoking essay written by a community health physician (Anita Sreedhar) and a sociologist (Anand Gopal) in the New York Times last week (Behind Low Vaccination Rates Lurks a More Profound Social Weakness https://www.nytimes.com/2021/12/03/opinion/vaccine-hesitancy-covid.html?smid=url-share) that helped me understand that the points of view of some anti-vaccine and anti-maskers can be attributed in part to a number of factors, including: a distrust of a government which has not helped them in the past, a differing hierarchy of needs for people living on the edge vs the rest of us, and the rejection of the concept of the common good, which emanates from feelings of being abandoned by the powers that be. The resulting mindset is that everyone has to look out for themselves, and no one else. Individual freedom above all else. It makes sense as a rationale for this thinking but it doesn’t solve the problem. Which brings me back to TB, specifically how public health departments handle TB to protect both the community and the individual.
If someone is diagnosed with active TB, they are mandated to take medication, and if they are not deemed reliable, they are brought in to a public health facility (or someone goes to their home) so they can be observed taking the medicine. This is called Directly Observed Therapy (DOT). It’s most definitely a thing as is the power of the health department to isolate contagious individuals and at times commit them to a facility until they have completed treatment (which is always a last resort and rarely happens.) Ensuring that these individuals are treated is in everyone’s best interest. It protects the infected by curing their disease and also protects the community at large from becoming infected.
So say one is anti-vax and anti-mask and anti-mandate and your next door neighbor who frequents all the public places you do and volunteers at your kid’s school has been found to have active TB. Would you fight for the individual’s right to sovereignty over their body even though they have the potential to infect the community and sicken the most vulnerable? Is it their right not to take the medication? If you are healthy, maybe you would only get LTBI if exposed, no big deal for now. But what if you are still recovering from the flu (you don’t get the flu shot, after all) and your immune system is weakened. What if one of your elderly relatives volunteers at the school too? Now TB is not the scourge in terms of virulence that COVID is. It spreads in the same way as COVID, through airborne droplets, but is not going to cause a pandemic because TB is slow while COVID is fast, and in many cases TB can be cured with medication. Also it can take a few weeks to become infected and contagious after a TB exposure, and as explained before, the latter might not happen if you are healthy. Still it is a nasty, potentially deadly disease with drug-resistant strains and life-long effects on health.
When I think of tuberculosis, I can’t help thinking of our public health departments and how important they are to the community. Humans are drawn to community for protection and social interaction. We naturally want to belong — to our families, our social groups, our local communities and yes, our country. Today our country is so divided. I wish more people could understand that the individuals working in public health, imperfect and strained as they all are, are doing the best they can to safeguard the health of as many people as possible, and this in the face of so many unknowns. That essentially, is their mandate. That’s what the common good is, the best outcomes for the greatest number of people. It’s hard to argue with that. Because if we are not all in this together, then what’s the point of being here at all? #thecommongood, #vaccinehesitancy #N95s #WritingCommunity #weallwanttobehealthy #tuberculosis #LTBI #Covid #endthepandemic
I’ve been thinking a lot about balance lately. Well balanced meals. Work life balance. Balancing needs in a relationship. Actual physical balance as in yoga and most other exercise practices.
Balance is a good thing, most people would agree. Balanced doesn’t have to mean even, it just means that there is some weight on both sides, even if unequal.
In health care, balance is most difficult to achieve. Even in a community health center (and I shudder to think how it is in a for-profit practice), providers are pulled in different directions. See as many patients as possible, stay on time, keep up with your charting and labs. Oh, and don’t forget the metrics that measure the quality of your performance. It’s one of the ways health care providers are evaluated these days. If you don’t press the button or check the box, your care isn’t up to snuff. Even if you took well-documented excellent care of your patient. How can that be right? The measures are correct, but the requirement of sometimes having to do double work to get credit for them, that’s not correct. Maybe in the future AI can read the note and give you credit for your thinking and care without you having to stop and toggle.
Don’t get me wrong, I love metrics. I have a probably unhealthy attachment to my Peloton and my Garmin watch which track my workouts. But when I’m using them, I’m just in the moment, exercising, I don’t have to do anything but what I’m doing to get “credit. “
I like to think I have a balanced approach when seeing patients. Open to their unique perspectives and ideas about their maladies but not so much that I don’t consider the other possibilities. That is, in fact, my job. Or as we say, taking into account the differential diagnoses: a list of possible explanations for a specific set or subset of symptoms.
There has to be balance in our communication with patients. You want to really pay attention to and listen to them but you don’t need their life story, and in 15 minutes there is also not much time for small talk. You have to cut to the chase to get at that vital piece of information that will help you rule out or rule in a specific diagnosis.
You want to discuss the abnormal test results. But you don’t need to go down the rabbit hole of every possibility and scenario following that one test, which could lead to needless stress and worry. One step at a time, together.
For both patient and provider, health care today requires a balance between the idealized view of practicing and receiving health care and the reality of too little time, too few resources and systems that seem to alienate the givers and receivers. I hope we can do better.
Is it better to give than to receive? I wanted to find out if giving the vaccine was as gratifying as receiving it. Since I already covered what it was like to get my shot, I am sharing my experience of administering COVID-19 shots, something I very much wanted to do, even though it’s not in my job description. What I learned went beyond the comparison of giving and receiving, into the concrete disparities between private and public health care and the people served by each.
But first, I got around the not in my job description part by volunteering (i.e., no pay) to administer the shots a few mornings a week. Instead of nice work clothes and a lab coat, I sported scrubs and white sneakers. How liberating, how comfy. It really took me back. Actually the last time I wore scrubs professionally was on a medical mission to Guatemala, but that’s another story.
Here are the specifics on all three vaccines. Skip to the next paragraph if you already know or are not interested in the nuts and bolts. All 3 of the COVID-19 vaccines are intramuscular injections into the deltoid muscle of the upper arm. At our clinic we have the Moderna which is a 2 dose vaccine, the second dose given 4 weeks after the first. For a time we also had the Johnson and Johnson Janssen vaccine with is a one and done as they say. Both are for people aged 18 and above, and the amount in the syringe is the same – 0.5cc. The Pfizer vaccine, which our clinic did not have, has to be mixed with a diluent (a special diluting solution) before being drawn up, and is 2 doses given 3 weeks apart. The dose each time is a little less in volume than the other 2 vaccines – 0.3 ccs. That one is good for ages 16 and above. The age ranges may change as the vaccines are undergoing testing for children. I won’t get into the efficacy of each one. The studies were done in varying conditions. Each one works well enough to prevent the majority of people from contracting the disease, and is even better at preventing severe illness and hospitalization. And that of course, is what we were all most worried about. Because if contracting COVID meant just a few days of feeling under the weather for everyone, it wouldn’t be a big deal.
As I began writing this, the Johnson and Johnson vaccine has been all over the news due to a rare clotting condition exhibited by 6 women within 2 weeks of getting the vaccine, one of whom died and one who is in serious condition. That’s 6 cases among around 7 million people who received the vaccine. When I learned they were all women aged 18-48, I immediately thought of oral contraceptives, which can cause blood clots. But apparently most of the women were not taking them. CVST (cerebral venous sinus thrombosis) is a very rare and very serious clotting disorder, which causes both clotting and bleeding. For now the vaccine is on pause but that reflects an abundance of caution, when you consider the numbers. The odds of getting that rare side effect are about the same as getting Guillain-Barré Syndrome (GBS) from the flu shot. According to the CDC, studies suggest a person is more likely to get GBS from actual influenza than the shot. Just as it is far more likely to get blood clots (and die) from having the COVID-19 illness vs getting the Johnson and Johnson vaccine.
This post was intended to be about the experience of giving the vaccines, so I will circle back. Every one of the people I inoculated was grateful to be getting the shot and grateful that there was a shot at all. Nobody cried although I’ve heard that it has happened — tears of joy and relief. I think the pandemic has made us all more emotional. When I received my first dose of Moderna in January, it was as close to a religious experience as I think I will ever get. Being able to bestow that feeling through vaccinating others amplified the exhilaration, the hopefulness. So yes, in this case, it is even better to give than receive.
As a vaccination site, we are open to the community at large, anyone whom the state deems eligible to receive the vaccine. This should be true at all sites who applied to be vaccinators, but in the local private practices at least, when they did have supply, they sent emails to their own patients with very specific admonishments not to forward the email. Point made. Conversely, in addition to our own patients, our waiting room fills with people who have never set foot in a community health center before, although most likely their housekeepers and nannies and landscapers have. There was a little sheepishness at times, about snagging the vaccine in a place like ours, but also, I hope, a new appreciation for what we do. To a person, they expressed surprise about how “nice” our offices were, how clean and professional. A little insulting, to be sure (what were they expecting, a MASH unit?), but I hope, as they sat (socially distanced and masked, of course) among our regular patients in the waiting room, their eyes were opened. I hope they realized how important high quality health care is to the people they employ or who serve them at stores and restaurants and grocery stores. How important it is that these people have a “nice”, clean, professional and safe place to go. Because the state of their health affects the health of the community as a whole. And never has this been truer, nor the stakes higher, than during a pandemic.
As an employee of a Federally Qualified Health Center (FQHC), I was in the first tier of health care providers designated by New York State to receive the Covid vaccine. I got my first dose of the Moderna vaccine on Monday and I was beyond grateful. As I understand it, most providers in our centers felt the same way. But about 50% of the other workers declined, despite encouragement and reassurances about safety from our medical director, who of course, led by example. It’s hard for me to understand. These are people who have face to face contact with potentially contagious patients and know first-hand how hard hit our community health centers have been. Our positivity rates are always much higher than the county’s, this week nearing 30%.
How I wish my husband had been able to get the shot at the same time, but even with a medical condition that could make him more vulnerable, he could not. In fact, at the end of this week. our centers have to gather the unused vaccine supply and give it back to the state to be redistributed. Some might take exception to this, reasoning that we could have used the supply to protect our most vulnerable patients. But our state is strictly operating from the top down, vaccinating the health care workers so they will be able to care for the sick. I think of it like the airline safety rule about putting on your own oxygen mask before helping someone else. I’m okay with it.
My response to the vaccine was minimal: a sore arm for about 48 hours and maybe a tad less energy the day after. And you know, I was glad to have some reaction which could signify a robust (at least adequate) immune response. I’ll feel as if I have some protection in 2 weeks.
Just heard that Biden is planning on releasing more vaccine instead of reserving the second doses as is the case now. More people will be able to get that first dose, which is good. My extrapolation from the studies available is that after about two weeks following dose one, the vaccine might be at least 50% effective, so from a community health standpoint, it makes sense. The risk is that there will not be enough second doses three to four weeks down the line. I still think this is okay. If the second dose is delayed by a few weeks, the only harm will be the first group will be less than fully protected. At least more people will be partially protected. And Moderna indicates they will be ramping up production.
In all of this, the decisions we make today are based on the information we have at the time. There’s a lot missing but we really have no choice. And no certainty. We all just have to do the best we can.
The Covid tests on my schedule are like the bread in a sandwich, first part of the morning and last part of the afternoon. It’s done like this to preserve PPE, a term sadly, everyone seems to know now. The positivity rate in our clinic is high — 30% — much higher than in the surrounding area. This is because our patients cannot afford not to work, even if the conditions are unsafe, even if they themselves are sick. They do not have the luxury of social distancing in their crowded homes, often with rooms rented out to strangers to help pay the rent. They are also Latino, for the most part, which puts them at greater risk as well. They tend to have comorbidities such as Type II diabetes, obesity, and high blood pressure, which may them more susceptible to the virus but undoubtedly makes it more dangerous for them should they contract it.
But today I am writing not about them, but about me. Which is selfish, I know. As I mentioned before, we have enough PPE, which is wonderful. Our medical director cares about our safety. We are directed to wear eye protection — face shields or goggles — as well as a medical grade surgical mask, to each and every encounter. When we are testing for Covid, we wear N95 masks, surgical gowns and gloves in addition to the eye protection. But still I worry. When positive results come back, I review the visit. Did I lift up my goggles just a bit to better see the computer screen? Was my mask gap-free all the way around? Did I remove the PPE properly? Did I avoid touching my face? Most of the time, after so many tests in a row, it is impossible to remember. And impossible not to worry about my own and my family’s health.
This is a second career for me. Being late to the game, I was never going to be in the ER or ICU. I wanted to be in community health. Far from being an adrenaline junkie, I take pride in getting to know my patients during a first physical and helping them on the road to better health. I like to cheer their progress and try to help them overcome the obstacles of chronic disease. It’s enough. Sure, it’s discouraging at times but the small victories are sweet.
That’s all changed now. We are encouraged to do virtual visits, which is sometimes difficult for our patients to manage. Still plenty of patients just walk in and sometimes, no matter how well the staff questions them, they only reveal their exposure to Covid and need for a test, to me. Who is not currently wearing an N95 and needs to back out of the room to get one along with a gown and gloves.
Of course this is nothing like what my compatriots on the front lines face every day. There aren’t enough words to express my admiration for them, along with the acknowledgement that I could never do what they do. This is about me (remember, I’m being selfish here) and my unglamorous and usually not life-or-death work-day. A day that used to be filled with physicals and pap smears and well-baby visits, with the occasional strep throat, UTI, or STD thrown in to jazz things up. Sometimes a grind, yes, but infinitely preferable to the current situation. What I did was important in its own way and I mourn the loss of that kind of routine health care. I hope in the not so distant future, the ability to deliver that kind of care returns.
I never learned to intubate, only suctioned a dummy, and can’t start an IV. Procedures are not my strong suit. The skills I pride myself on — diagnostics, well visits and health screenings, follow-up of chronic health conditions, and communication, aren’t particularly useful in the thick of the pandemic. I’m sure they will be again, but for now, I try to use my training to make sense of the science and to advise friends and family when they ask. Or in the case, of my children, even when they don’t.
Before I go on, a caveat: this information should not take the place of consulting with your health care provider. Especially if you are vulnerable due to a compromised immune system, age or other health conditions, you should follow expert advice to the letter and err on the side of caution. The CDC and local department of health websites are excellent sources for timely information about best practices for protecting your health in this changing situation. Think of this as my attempt to share, in layman’s terms, what I believe, and what I am doing currently for my own well-being.
In terms of the science, there is so much unknown. When I first started hearing about the virus’s infectiousness, I questioned whether it was spread solely via droplets as was being reported. The way the virus has spread appears more like a hybrid of droplet and airborne contagion. Both tuberculosis and chicken pox spread through the air, which explains why they are so very contagious. We’ve also learned that duration of exposure and dose of virus particles are key to whether you are going to get infected, and perhaps how ill you will become. Of course, age and other health conditions also play a role. But we have seen young, healthy people get very sick and even die, while some nonagenarians survive. And then there are questions about genetic immunity, whether it’s blood type or some other genetic determinant that makes the lungs more susceptible to the havoc Covid !9 can wreak. We will understand so much more of this in time, but for now here’s what I do, and suggest others do to be safe without going crazy.
When you leave your home: Always have a mask that covers your nose and mouth ready, in case you cannot maintain a distance of at least six feet. I am a runner and hate running with a mask on – it makes me gag. But I have one around my neck before I venture out for a run and if there’s a chance I will come closer than 6 feet to someone, I put it on. Always wear a mask when entering an enclosed space. Avoid touching your eyes, nose and mouth. And wash your hands for 20 seconds as soon as you enter your home.
Grocery shopping. From what we think we understand at this point, the risk of contracting the virus is inversely proportional to the amount of time exposed and the dose of the virus – ie, whether you are exposed to copious secretions of an ill person up close. So masked, socially-distanced-grocery shopping is not as risky as we once thought it was, as long as you take precautions. Have a list and be efficient so you can limit your time. Sanitize your cart. Use hand sanitizer once you are back in the car, or when your leave the store, if you are walking.
Taking in mail and packages. While the virus has been said to exist on surfaces up to 72 hours in ideal conditions, keep in mind that conditions outside the lab are not ideal and viruses are notoriously fragile. At the onset of the pandemic, I used to leave the mail and packages on a table for 48 hours. Now I am not as worried so I am just careful to thoroughly wash my hands after handing deliveries.
So far these are all caveats, and isn’t it tiring to always hear what not to do?
Here are activities and routines that help me feel better during this stressful and uncertain time: Maintaining a healthy diet with lots of fruits and vegetables and drinking plenty of water. Sticking to a regular sleep schedule. Not overdoing it with the alcohol. Exercising vigorously 3-5 days a week and getting outside every day. Plus limiting the times I check news and social media during the day.
These are the health-related items I tell my friends and family to have on hand: A thermometer, acetaminophen, and a pulse oximeter to measure your oxygen level if you get sick. This last item will help your health care provider determine how your lungs are functioning and whether you might need to go to the hospital for breathing assistance. A spirometer is also a good thing to have to exercise your lungs if you are sick. You likely used one if you’ve ever had surgery. All of these items are available on-line and some at drugstores.
Okay, what else? I for one have been trying to live more in the moment, not a natural thing for me. Setting some time aside to meditate, or just breathe slowly and let your mind wander. Just a few minutes will help and is worth it no matter how busy your lock-down life is with work, childcare, school. Plan things for which you can look forward with happy anticipation. A walk in the park, a game or book. And yes, this is the time to binge watch for entertainment. Definitely schedule virtual meetups with friends and relatives even if they feel artificial at first.
Looking ahead. Yes, things are loosening up, for sure. The other day we had our first social event in real life since the lockdown. We sat on our next door neighbors’ open deck at our own table at least 6 feet away from theirs and we brought our own libations. But no masks since we were outdoors. It felt incredibly liberating. We will plan similar gatherings, but at this point, always outside and socially distanced. We might consider sharing food in certain situations but will be especially assiduous about hand disinfecting and not touching ones face. That’s it for now. Stay well.
I find the magnitude of consumption of health care frightening, and I’m a health care provider. I’m not talking about preventative care, which I think, if anything, more people should consume. And of course people must seek care for sickness and trauma. I am referring to medical testing and specialty care.
Medical tests such as blood work and imaging studies (x-rays, MRIs, CT scans, and ultrasounds) are overconsumed. Most health care providers, in their personal lives, are quite prudent about their own consumption of medicine in general. We know that every test has a downside and we want to be sure the information it will provide overcomes the potential risks.
Many people, particularly those with very good insurance, think when it comes to testing, more is better. I understand that some people really want assurance that there is nothing wrong. My Spanish-speaking patients frequently ask me — “favor de chequear todo” — to test for everything – including all cancers, to get a clean bill of health. Of course that is not possible.
Another type of excess consumption occurs when patients want to consult a specialist for the most minor of complaints, ones that could easily and safely (not to mention more economically) be taken care of by their primary care provider. Specialists are a great resource but if one sees a myriad of specialists more than your primary care provider, sometimes health care suffers. It is very possible no one is stepping back to take a holistic approach to you as a whole person, not just a foot or a heart or a GI tract. Patients don’t always tell their PCP which specialists they’ve been to and specialists don’t always send a report, especially if the patient has not provided a PCP because they don’t need a referral. Contrary to popular belief, providers don’t all know each other and records don’t magically get sent to your provider’s office. This is especially problematic when medicines are prescribed and there is not a complete list which would make checking for potential interactions possible. You as the patient need to be pro-active about this, for your own good health.
While it is true referrals are a pain for all concerned, the concept of a gate-keeper for your health, i.e., the PCP, is a good one. Yes, insurance companies use the referral mandate as a way to cut costs, but the upside is that your PCP knows what is going on with your health. We can help you determine which kind of specialist to see, if warranted. Often this is not as clear-cut as one would imagine. So even if you don’t need a referral, you might want to talk to or message us about what is going on and why you think you need to see a particular specialist.
That being said, there are some medical offerings I wish my patients would consume more of. Screening colonoscopies and flu shots come to mind. I sometimes have to have to push very hard for both. Hope you got your flu shot this year – it’s still not too late. While it’s true it’s not as effective at preventing the flu as it’s been in past years, the efficacy is still around 30%. Way better than nothing. Plus the flu shot mitigates the severity of influenza if you are unlucky enough to still catch it. I was very grateful for even this level of protection when I was taking care of patients with influenza last week.
Stay healthy, and be mindful of your medical consumption.
When a loved one recently had a scary diagnosis and surgery, we found ourselves on the other side of the stethoscope, so to speak. I took my own advice. (See post: A Bad Diagnosis) We researched, got a second opinion and made the best possible decisions we could at the time. We chose what we believed was the best hospital, and the best surgeon for this particular case. Then we just had to wait to get scheduled.
One of the hardest parts for me, as a health care provider well outside her field of expertise, was relinquishing control and not focusing on minutia. When I found myself, having never performed any kind of surgery, up in the early hours researching the merits of different surgical clamps, I realized I had to let go and the let the surgeon do his thing.
For the most part, I wasn’t in a hurry to reveal my health care background once we were in the hospital. As I frequently say “I’m not that kind of nurse.” Not the kind who executes hospital procedures with ease or can scan an EKG in seconds. Not the kind who can fix a misbehaving infusion machine with the press of a few buttons. Or the kind who can matter-of-factly inflict pain when necessary. (Still don’t like giving injections.)
Basically, I didn’t want to get in anyone’s way, or interfere with the practiced execution of care. Still of course, I was watching. So I noticed that a loosened tourniquet was the reason a nurse couldn’t get any blood out of my husband’s arm. I wordlessly retied it. Or when I blurted out in recovery that his pulse ox was a little low and got that bemused look from the nurse, before she gave him some supplemental oxygen. It was okay though. I fessed-up and we chatted about NP school.
Once on the floor, I kept careful track of his pain med schedule and asked what was being given if the nurse did not explain. She usually did, though. (No male nurses on the floor when we were there.) Change of shift, as it was when I was still in nursing school, was a chaotic time, resulting in delays moving from recovery to a room, and also in getting discharged because of something that wasn’t communicated.
An advantage to usually being on the other side of the stethoscope is an understanding of how things work, how busy people are and knowing not to take up their time unnecessarily. My husband does not like to rock the boat and there were a few times I wanted to call the nurse (or have him call her) to remind her we were awaiting a lab result, or pain medication and he stopped me. My “nursey sense” alerted me there was a problem, and in both cases, was spot on.
This experience was revealing in a lot of ways. I don’t know if nurse practitioners communicate to their patients differently than doctors do, but we resented when we knew results were in and there was still a delay in communicating them. This didn’t happen across the board but it did happen. I always call my patients ASAP with results I know they are concerned about. Of course, if the news isn’t good, I need to have a plan for next steps formulated. But I don’t delay for days until everything is in place. I feel comfortable saying: we are going to refer you to this type of specialist, I am just awaiting a callback so that we can get you in as soon as we can. In our case, we waited unnecessary, agonizing days for results.
Some good things. Our surgeon was an excellent communicator. He was easy to read and was able to read us as well. And whenever he did stop by, no matter how busy he was, he always found a chair to sit down and talk with us. That face to face time, eye to eye, meant a lot. I will be more conscious of that with my own patients, when I’m on the other side of the stethoscope.
