Friday, May 27, 2011

But I also have successes

I wrote that other post in class last night, just didn't get it posted until this morning. Overnight, I was thinking about some of my recent successes as a doctor. Those are much more common. In fact, like I said, my patients are extremely loyal to me for a lot of reasons -- probably because I do spend a lot of time counseling on things like diet and nutrition, and because I care so much about their growth and development. My schedule is usually booked a couple months in advance (it doesn't help that I only see patients once a week), and I'm (unfortunately) always the nice one who agrees to be overbooked or to see patients when they arrive late.

So here are a couple quick stories just to let me feel proud of myself:

A few weeks ago I picked up a very early appendicitis on a 6 year old girl. So early, in fact, that she was out of the OR about 4 hours after I saw her in clinic (on Sunday morning) and home 24 hours later. Most kids under the age of 10 are so bad at identifying where their pain is, that they aren't diagnosed until after their appendix has perforated. She was clearly guarding over the appendix when I examined her, despite pointing to her tummy when I asked where it hurt, that I sent her to the ER for an ultrasound.

I have another patient I've been following for a few years who is also obese. She came in last summer (at 11 yo) having grown taller and had lost a couple pounds, for an overall significant reduction in BMI %. I was so proud! I asked her what she had done that was successful, and she said she had followed my advice to eat at least 3 different colors at each meal. I've found that's something that kids around that age group can actually understand and take control of, unlike portion sizes, calories, fiber, etc. And it worked for her! She was careful to have something green and something red, orange, or yellow at every meal.

Plus there are the kids who actually get into Early Intervention appropriately and learn new skills from their therapists. Or who follow-up with me appropriately and just are generally healthy! It makes me feel really happy when I see someone for a check-up and only have to spend a few minutes with the family.

So there you go. Have a great weekend!

Thursday, May 26, 2011

My failures

Two posts in one week? Don't have a heart attack. Seriously.

I've had requests in the past to blog a little about my work, so I'm sitting in a class right now, waiting for them to figure out the projector, and I've been thinking a lot this week about a couple failures I've had that I thought I'd share with you.

I love being a pediatrician. I think I'm a pretty good doctor, and most of my patients are extremely loyal to me (they hate when I'm away, or they can't get appointments with me, or they are sick and have to see someone else on a different day of the week than my regular clinic day). I also think I'm a pretty good teacher and hopefully helping to shape some other budding primary care pediatricians.

But I saw two patients recently, both of whom have been in my care for a while, and both of whom I feel like I've really failed. And it bums me out. Not sure I can or could have done anything differently. But it's hard being a primary care doc and dealing with these issues.

One is a girl who is nearly 11, so I've known her since she was 7 -- JF. Like many patients in East Harlem, she has bad asthma and is obese. For the past 4 years, I've spoken to her and her Mom (who is also obese) regularly about making changes to her diet -- namely cutting out juice and other sugary drinks, eliminating fast food, and having healthy snacks available. One of the barriers for this particular patient is that after-school she goes to Grandma's house, and Grandma always has cakes and cookies and brownies available. JF is hungry, so she indulges, and Grandma loves to see her enjoy herself. The other big problem is that she eats lunch at school, and they serve things like chicken nuggets and pizza -- not salads or grilled chicken.

So she shows up last week for a follow-up visit. Thankfully, her asthma is well controlled (she has one PICU admission since I've known her, but hasn't even been to the ER in over a year). But she actually gained weight since the last visit, when the goal for kids this age is to grow in height without gaining anything in height (yielding a lower BMI). She is over 150 lbs! When we started talking about things like juice intake again, it's like she's never heard that she shouldn't be drinking the stuff. In one ear and out the other. And her Mom just sighs and shakes her head, not realizing how serious this can be -- diabetes, heart disease, high cholesterol, not to mention the social issues. Sigh. I don't know how else to get through to them. I keep repeating the same things -- about diet, and exercise -- keep giving her the same advice, visit after visit, year after year. I'm a broken record. But I don't think it's working for her.

The other patient makes me even sadder. WR is now 3 years old, and has been my patient since he was born. Looking back through his chart this week, at the one year visit Mom asked me about some of his behaviors -- namely, his tantrums -- but I reassured her that they were normal 1 year-old behaviors and that he was developing appropriately. By 18 months, however, I noticed that he was not behaving appropriately for his age -- his social skills were lacking. I tried talking to Mom about it then to get him evaluated, but at that visit she thought he was fine and told me that what I was seeing in the office was NOT how he behaved at home, and that his language was much more developed than I was seeing, he was just being shy. So I didn't push it, but wanted them to come back sooner for a follow-up visit -- they didn't. At the 2 year visit, it was very clear to me that the child had features of the Autism Spectrum Disorders, and I encouraged the family to get him evaluated by Early Intervention immediately so he could get started in therapies. They refused to believe me. Dad has an older son with autism, and stated that WR has none of the features of the older boy so it couldn't be true. At 2 1/2 they finally agreed to get him evaluated. The people from EI came in and all of the therapists used the word "autism" or "autism spectrum" so the family got mad. I saw him last week on his 3rd birthday (when he ages out of EI and has to place into school-based therapies). They are angry about the evaluation because they still don't believe he has ASD. They don't want to accept the diagnosis and want 2nd opinions. Meanwhile, the kid has every feature of Pervasive Developmental Disorder (which is on the Autism Spectrum) you've ever seen. He has no significant speech other than "juice" to refer to all food and liquids. He makes minimal eye contact, talks/sings to himself, plays by himself, etc. I tried to convince them to just accept whatever diagnosis the therapists want to make if that means he qualifies for lots for lots of therapies, they can think whatever they want to themselves. But it's difficult. This kid should have started therapy at least 18 months ago and I feel like I failed him.

So there you go. It's frustrating to be a doctor.

Friday, May 20, 2011

Happy Friday the 20th!

The post below was originally written last week, but blogger was down. For the sake of time, since you are all shocked I've posted anything (yes, I see it's getting to be a trend, every 2 months....), I'm just going to post it as is. I'll try to post an update on Monday. Happy weekend!!


Happy Friday the 13th! Well, I actually wrote this post on Thursday, except Blogger was down so I couldn’t post it. I had an hour to kill between “I don’t feel like doing any more work today” and class, and realized it had been, yet again, nearly 2 months between Blog posts. So I decided it was time to update my 4 loyal readers about my life.

Since you last heard from me, I took an impromptu weekend vacation to the Bahamas, spent a week in Alabama (for Passover), and went to Denver for a Pediatric conference. That’s a lot of traveling for someone who also spends one weekend a month (sometimes more – 2 in May) on call, and works 10-12 hours a day.

Why so much traveling? I had a long weekend the 1st weekend of April – it was “spring break” from my masters’ program, and I had originally asked for the day off of work months ago when I thought there was a possibility we’d go to my cousin’s wedding (but unfortunately, my Dad couldn’t afford to go, so that family trip got canceled). S and I discussed going to a B&B for the weekend, but everyone nearby – like the Hamptons – was super expensive. Plus the added expense of renting a car to get there, and it didn’t seem like a cheap getaway. And it was super cold here. Snowing, in the 20’s. Nasty winter weather. So we looking online to see where we could fly that was sunny and warm. The Bahamas on Jet Blue! Went on Priceline and got a room at the Sheraton in Nassau for less than $100/night. Brought a lot of our own food so didn’t have to pay for the expensive resort food. Sat on the beach, relaxed, read. Went snorkeling, which was fun. It was just what we both needed.

The Alabama trip was planned for a lot longer. S & and I both went for an entire week, got to spend some time with both my real family and my “adopted” family, the Chabad family in Birmingham with whom I’ve spent all the holidays (especially Passover!) for the last 20+ years. The only bad thing was that spring was long gone in Alabama this time of year, everyone was already green instead of blooming, so S didn’t get to see all the pretty pinks, red, purples, and whites that I am used to seeing around the Passover/Easter season. Oh well, there’s always next year. J I only had 2 days at work before leaving for the Denver trip, and since my expenses were covered by work S decided to tag along for that as well. The conference was amazing, I learned a lot but also just got to spend time with other people in the academic world and get ideas for new research topics and hear what the latest findings and trends are. Denver is a beautiful city and I also got to see some cousins there I hadn’t seen since I was about 13 or 14 years old!

So what’s next? I’m being kicked out of my apartment – my landlord decided to sell the place instead of lease it to me for another year – so S and I are looking at things together. Not because we are moving in together – I’m too old-fashioned for that – but because we think that it makes sense for me to find a place now where I don’t have to move again in a year, so it should be big enough for both of us so at some point in the next year he CAN move in. But it’s stressful to find an apartment in NYC. There’s all this pressure that if you find a good place and don’t take it right away it will be gone (it will be), but what if something better is available tomorrow? Plus you have to prove your worth: you have to make 40X the annual rent (or have a guarantor), so since it’ll only be my name on the lease it’s an added complication. Based on my ACTUAL salary, before all the moonlighting I do, I’d only be approved for something around $1500/month! That’s less than what I pay now for my studio. So then I have to prove what my actual salary is, and all of that. And then you have to decide if you want a doorman building or a walk-up, and a pre-war building or a modern building. And is it worth more $$ for less space, in a fancy building that has amenities like a gym/pool/movie theater? Do I really need a view? Etc, etc, etc.

But onto the big question – you want to know about me and S and the big question, don’t you? Things are good, and progressing as they should. A lot of people said “oh, he’s going to propose!” when they heard we were going to the Bahamas in April, and so when he didn’t I was a little sad. So I told him about it, and it made him sad because apparently he didn’t realize that I would have thought that, but he had been having a hard time finding the perfect ring. So since then I’ve stopped worrying about it because I know it’s going to happen at some point, and when it does it will be special, and I also don’t want to ruin any surprise! (Although I told him once that I’ll know he’s about to propose when he takes charge of making plans one night, since usually he leaves the planning up to me.) Yesterday (Wednesday) was our 9 month anniversary! It feels like I’ve known him my whole life, and sometimes it feels like I’ve only just begun to learn things about him. He’ll wonder how I’ll know something about him without realizing how well I already know him. But then I find out things – like that he’s never seen any of the “Back to the Future” movies – and I’m so shocked that I’m dating this guy! Ha. Never any big, scary things. Although that is kinda big and scary. How could someone never see “Back to the Future?”

And there are more trips coming up! We are going to Israel in a few weeks together! I won a free ticket back in October, from El Al (they ran a twitter contest). Unfortunately, I won the free ticket about a week after booking my ticket for my February ticket (and that ticket was non-refundable). The free ticket couldn’t be used over New Year’s or Passover, and has to be used by June 15th. Since I would have taken off a couple days for Shavuos the first week in June anyway, we decided to go for that whole week. El Al is smart, they are making money on his ticket that we never would have spent otherwise! We are staying in Jerusalem for 5 nights and Tel Aviv for 2 nights, and don’t have any real plans, so if you have suggestions on fun/different things to go please let us know. (We are both veterans of Israel, this is my 9th trip and I believe his 4th or 5th.) We were thinking of Hebron for one day, if anyone has had a good or bad experience going there please share. And then there's a super exciting trip to Destin (on the panhandle of Florida) over July 4th weekend. I grew up going there every summer with my extended family, and this year we are doing a cousins' trip -- just my first cousins, no "adults." I'm excited to introduce S to the beautiful beaches there -- the "redneck Riviera."

And I can’t believe that I’m almost halfway done with my fellowship! With very little to show for it. Nearly ready to submit my IRB proposal, hopefully it will get fast-tracked (it’s just a chart review so is exempt from most things) and I will be able to spend my summer wading through hundreds of charts. So fun, I can’t wait. :-P Just hoping to have something interesting to report in the end.

Alright, time enough wasted. Time to grab a snack before my two hour class! Since you’ll be reading this on Friday the 13th, hope no black cats cross your path and no ladders impede your sidewalks.