Doing well!

Long time, no see!

I'm in a contemplative mode right now, so I figured I could write an update. My social anxiety is better than ever. I'm feeling funny at times, but I just acknowledge it and brush it off: it's just like having a runny nose: just take a tissue, wipe your nose and move on. No big fuss. Just yesterday I casually invited my brothers in law out for lunch... me? alone with guys other than my husband?making the invitation without any hint of hezitation? - who's this girl?

I dropped yoga for a long time, and I just got back to it this last week. I am a different person, I found back my anxiety-free world. I see now that I have conditioned myself to be anxiety-free when doing yoga. So I need to keep on doing it. It's great!

I will be moving out of the country for 6 months and I am quite emotional and observant about everything around: admiring my neighbourhood, the trees, the birds, my car. I am packing my whole house and it's great to touch each object. Bring back memories.

For those of you that were around at the time when I had an impossible dream, the dream became quite possible. I am taking an online course of Health Care for IT Professionals and doing really well and I think by the end of this course I will be able to find some work. My doctor was already interested in me coming to review her workflow and help with their new EMR system.

The conclusion is: social anxiety can be beaten without medication. You can achieve your dreams no matter how crazy they seem to be. Just don't give up. Keep pushing yourself. But you need to know what you're pushing for: clarify your priorities and your goals.

Growing pains

I think I'm growing a bit these days.

My first revelation is that it's unfair to judge anyone because you can never know everything that is going on with that other person. Unless you know all the factors how can you say whether someone is doing or not the right thing. This has to do with my last post and with my previous rants mainly about doctors. I got to understand a bit more about a couple of doctors that I complained about in the past. I got to see how one of them is really trying to do things better and I think this is what is important: continuous improvement rather than perfection.

My second growing point and the answer to all the people that get to my blog by searching for "is social anxiety ever going away" and "emotional immaturity" is that I will live with social anxiety for the rest of my life. It will not get better. I might lose jobs, opportunities, friends, relationships, etc. over this and this is OK. Other people are losing jobs, opportunities, friends, relationships, etc. over other things. I will have to accept it, live with myself, get over it as fast as possible and move on. Emotional waves will come and go, some will be stronger and more painful than others. I just need to know that they all will go away eventually.

I met someone that might be useful in achieving my impossible dream. I was breathless, speechless, said the wrong things, had the wrong attitude. It will not go away. I might fix it by sending an email or going back, or maybe not, but the only way to get that job is to continue to do this over and over again until it becomes so normal that I can do it without overwhelming emotions or until someone will be able to see through the emotional content. Either way the emotional maturity and the social anxiety won't matter anymore. The only person that this is a big deal for is myself.

It was painful to see someone interested in what I had to say and seeing me running away from talking about what I want to talk about most.

I will try to work on a marketing speech to help me get through easier, but I will expect even this to fail. I cannot win if I will always run away.

Malpractice

I read this article in Medical Economics and I got offended.... big time offended. You advise doctors to write notes that detailed to avoid a malpractice suit? This mean doctors spend more time writing notes than they spend talking to patients? And this for the 1% or less patients that would sue them?

Can't they come up with something more economic? Can they record the conversations during appointments - that would embarrass us a lot, but how is it different anyway? It can only be used if you sue them.

Can we come up with some promise that we are not set to sue them? Like marriage? In sickness and in health... We're not all after you! Shouldn't the lawyers work on doing something like that than on suing doctors... I guess that wouldn't bring enough money.

When I had a breast lump, I had two doctors give me breast exams without a chaperon. I very much appreciated their ability to see me for what I was - a scared woman - rather than a malpractice suit waiting to happen. These doctors gained my full respect. Of course I wouldn't blame anyone that uses a chaperon (you need to do what you need to do), but having the guts to do otherwise needs to be appreciated.

What a mess!

Where does the medical interest come from?

I got a new reader (Hi C and welcome!) and she asked me a good question: why the medical interest.

I always wanted to be a doctor. My grandfather was a surgeon, family physician and ob-gyn. In his 90s, his hands were so precise that he would walk with a cup full of coffee from the kitchen to his room without spilling a drop. At 80 years old, he was doing a spinal taps, one of them right when a big earthquake happened. He was very respected and everybody was wishing that someone will follow his steps. I would have liked it, but when time came, the status of health care in Romania was pretty bad and doctors were not seen as having a bright future (he he, talk about the American healthcare being in bad shape...). On top of that the admission exam was extremely difficult and i never thought I would ever make it. Right now, I think I had good chances anyway, but at that time my self esteem was very low and no one around me told me otherwise.

Life seemed to take me farther away from medicine, until I got hit with preeclampsia. After the initial shock with this not well understood disease, I got every book I could find on the subject and some of the books were medical textbooks. I found the Preeclampsia Foundation and a group of people that were just as nuts about finding answers and learning more (even if that meant housewives reading medical textbooks).

I learned and understood a lot in those years: I learned how little is known about pregnancy, I learned that doctors are not Gods, I learned that we need to take responsibilities and to accept a degree of risk. After the initial: "you doctors are all idiots" phase, I learned to respect doctors and medical professionals and I tried as hard as possible to communicate effectively and help them help me. It was a long road with lots of bumps, but I ended up feeling very comfortable with the doctors I sticked around and I feel I have a good grip on navigating through the health system.

After my second pregnancy, when it looked like preeclampsia was out of sight for a while or maybe forever, I attacked the anxiety with a new set of health care system challenges: finding the right therapist, deciding on meds vs. therapy or both, etc.

While working on the anxiety, I realized that I had the freedom to have dreams and that no matter how unlikely these dreams are, I can still have them. There is no shame in dreaming. I found Paul Levy. Paul is not a doctor, but he does a great job being the CEO of a large hospital... so maybe my dream is not that impossible either. Add to that that I am working in a field (IT, database software development) that is needed like air in healthcare today, and the dream seems just around the corner.

Are you ready to use props?

When you are very fresh in a yoga class, you are usually told that you can use blocks and straps to help you through the poses. Unfortunately, when really new to it, there's no way you could do that without help: you try so hard to do some of the stuff, that you can't even breathe and much less scoot around for your block. If you go out of the pose, you feel that you would never go back in again. As you gain more experience and strength, you are able to breathe, move easier and figure where you need some help, and get your blocks and straps to help.

By reading medblogs, I found out that the new year just started for medical interns and residents and likely they are in completely new and scary roles and can't hardly manage to go through the day. Therefore I completely understand the poor resident that I am going to trash in the rest of this post.

OK, here's the story:

I'm going for my appointment to find out the results of the colonoscopy. I was very happy to finally get to talk to a gastroenterologist so I could put into perspective all the various complaints that I had during my life.

I get to do the vital signs part quickly and I am planted in an exam room. I wait there until about 1 hour after my appointment was scheduled. A resident and a medical student eventually come in. The resident states his name and starts asking me about my symptoms. Asks me to sit on the table and does an exam. I politely and slightly joking ask him what the results of the colonoscopy are. He pompously tells me that the doctor is going to talk to me about my results and the treatment and starts writing in the chart. I am amused and amazed at how little interest he has in me as a person. For this guy, I am just a set of interesting bowels... if even interesting (maybe GI is not his desired specialty and he just wants this over with).

The med student figured the awkwardness of the situation. She introduces herself. She asks me what other symptoms I had. I say a few things and then get frustrated with the resident's incapacity to treat me as a person. I stop talking. The med student asks me if this was my first colonoscopy. I answer yes. (what a great prop she handed the resident - first colonoscopy... she must have questions, right) The resident keeps ignoring us both. I am a bit frustrated, but things are still OK as I know that I will eventually see the doctor.

After another 15 minutes, the doctor and the rest of the guys come in. The doctor is quite young, but he looked bright and cute when he did the colonoscopy. He's telling me that I indeed have ulcerative colitis, and explains the treatment. I ask how long will the treatment take: he says he has no idea, it's a wait and see. He hurries toward the door. As all three of them almost head out, the med student asks if I had any questions. My frustration bursts out, and the doctor figures that something is wrong with this picture. He sends the resident and med student away and insists that I ask my questions. I get to ask my questions and understand a bit more about my condition. I am relieved and happy. I stopped being a set of bowels.

I am told that most patients are very happy with this kind of treatment.. as long as they have their prescription and their pain can go away. When I complain about the delay, I get apologies and I am told that's because he takes time with his patients. I had to laugh out loud at this one. Come on guys, do you still expect us to believe that? It's just bad management, not all that wonderful quality time that you give to your patients.

Many thanks to the med student that saved the day and I hope the poor resident will be able to get the props soon as he gets used to his new role. As for the young doctor, what are we turning these guys into? All in all, I think it was a learning experience for all of us.

My anxiety: I got very frustrated and I had my moment of emotional immaturity: I insisted that I leave upset and that I don't want to talk. Fortunately, I got over it and after taking a few breaths, I could concentrate on my questions. The whole experience was so emotionally intense for me that I cried as I got into the car, but I was OK with this and the whole event. I could have been more mature, but I don't feel that I needed to. I am happy with myself. I still have social anxiety, but I am not viewing it as a disaster, just living with it. I guess I got to the point where I can use props if I need to :)

We are not broken TV sets and you are not TV repairmen

I was planning to write a mini-series dedicated to computers and IT in general, but I just had another (rich in anxiety) healthcare experience and I neeeeeed to talk about it.

As I see it, having colitis is pretty straightforward for doctors these days in US. You have the symptoms, they have the luxury of seeing what's going on with a colonoscopy, they figure what's up. They give you ASA first, if it doesn't work, they give you steroids and so on. Just like fixing a TV: the image is flickering, so you get a flashlight, open the back cover, peek inside, find a burned something, replace it, still doesn't work, you go up the stream until you find something broken and the TV now works.

Just that we are not TVs, we are humans. And even though you have tons of pressures with administration, too many patients, too little time, and who knows what else I'm pretty sure you didn't go to medical school to find out how to peek in assholes and write prescriptions. I bet you went there to help people in need, and to have human contact. So where in the process did you lose this? Why did you become insensitive machines?

I realized today why would someone like to do Gastro/Enterology. I think you have the opportunity to offer more relief and be in more intimate human contact than almost any other specialty. Even more than gynecology, pretty much at the same level as obstetrics.

I don't know details about all the gastric/intestinal diseases, but in our culture, we put so much emotional content in our digestive system... think of all the bathroom jokes, of the big laughs on burps and farts. So, here you have someone that is scared enough to come see a doctor, after a lot of embarrassment at work or in public places, after avoiding to be too far away from a clean toilet because the bathroom becomes a very common place. Oh the growling stomach and the rushed trips to the bathroom, and the horror of checking what's coming out and the daily cramps.

Maybe you indeed do not need to know all the details of our symptoms, because you have your solutions, but we need to finally tell someone and there's a big trust that we put in you. Yes, we too are embarrassed to talk about our bloody poops and our smelly farts, but you are the only ones we can talk to about it; when we are finally ready to talk about this, please listen to us and try to empathise. And maybe, if you do listen carefully, you will eventually be able to tell us more than you tell us these days, one day you will be able to make connections between all that ails us and can suggest ways to prevent it in the future without drugs.

I ended up being listened to and I asked my questions and I got a few answers. And all is well if it ends well.

I will comment on the other aspects of my adventure in later posts, but, if you are a doctor, other medical professional or a medical professional to be, please always remember: we are not broken TVs, and you are not just repairmen.

More along the same lines in a post from new blog I added to my to read list: Surgeonsblog. Check it out:

http://surgeonsblog.blogspot.com/2007/06/shoefoot-other.html

And another one :)

http://www.memag.com/memag/article/articleDetail.jsp?id=438103&ref=25

Doctors don't need admins to show them how to do their job....

First of all, I need to say that I have no business or knowledge to comment on the stuff below, but this is my blog, so I'll do it anyway. I am just a software developer and a health care administrator wannabe... I will likely find other ways to fill my life before I'll ever get there anyway.

I mentioned a few weeks or months back that I like Dr. Wes's blog. I love his posts and I also learn new things about hearts (real ones). As with other people that I like, I find it very disturbing to read that there are things that we do not agree on. I need to work on this, but this post is a commentary on one of his posts that I don't agree with.

http://drwes.blogspot.com/2007/06/clipboards-or-care.html

I don't know enough about the exact details of the deal to be able to disagree with the entire post, but here's what I didn't like

Once again, it appears that hospital administrators would rather turn to
non-medical auto-industry "efficiency" and "safety" experts, rather than asking
health care professionals to recommend the best way to improve care.
...
Do we really need yet another company or administrator to tell us how to do
our job? Is it all about safety and efficacy? Or might providing a better
nurse-to-patient ratio be far better at improving care?

I am sure we are all frustrated with the health care status: patients, doctors, nurses, etc. But I think that a big part of the problem is the administration. If administration is telling doctors and nurses what to do, it is wrong, administration should empower them to do their jobs and take care of all the non-medical stuff so that they can do their jobs.

In software development, we say that the modern project manager is no longer a supervisor, but a partner that helps developers to do their jobs without needing to care about budget, time constraints, getting approvals, having the right hardware or software to do their jobs, etc. They just tell us what to do in what order and when and ask us what we need to get this accomplished in terms of time, and resources. Then they make that happen: they supply the resources and let us do our job.

That's what hospital administration should do, no more, no less. From my perspective as a patient, it's not the doctors or nurses that I am complaining about, it is the administration. I think that medical office staff is shortsighted, I think they don't get it, I think they perpetuate the idea of doctors as "Minor deities" (BTW, wonderful post, Paul! Yes, I too love my doctor but hate the system). They act as if they don't care about our time or our pains. Customer service is so poor. I doubt that I am the only one that is more annoyed about trying to get an appointment or try to get a doctor to call back then it is to actually talk to the doctor. In Romanian we have an expression: "on the way to God you get eaten by the angels"... I can't think of a better metaphor for what's going on.

So why not let the administration learn more from other industries? They do need to learn. They can't do it from their peers, most of them seem stuck in the same hole.

Just this week I went to the hospital to have a procedure. I love to look around and see what's good and what's bad. So while looking around I see a chart: customers satisfaction surveys for nurses: 100% ... my, my, these guys are already perfect, there's nothing better to be done.
(I think that the book "If Disney Ran your Hospital" - by Fred Lee is wonderful and right on target on this). And, of course, the poster with: if you can't give us a 5 just call the nurse manager and she'll fix it for you - guiltying us into giving them only 5s. Oh, well!

The hospital is wonderful and the nurses and doctors were great. It was a good experience, not a memorable one, but good enough. I don't have complaints about doctors or nurses.

But they call the patients one hour and a half before the procedure is scheduled... Why? Why not 30 minutes, maybe even 15 minutes? After all, all there is to do is to sign a bunch of papers, and get undressed. They take a medical history and they put in an IV, but all this stuff is done in L&D in less than 15 minutes.

I didn't get the impression that there were too few nurses... maybe they are overworked, I don't know. They do plan the same number of patients, so what difference does it make to them that we stay there an additional hour? All I can think of is that if someone cancels or comes late they want to be sure that the doctors and nurses stay occupied. But is it worth? Shouldn't administration ask and find a solution to this particular scenario without inconveniencing the patients? Maybe this is what "lean" should mean?

Dealing with emotional people

I am reading If Disney Ran Your Hospital by Fred Lee. It is a wonderful book. I am surprised. I am surprised that such a great book on health care management exists and so many hospitals and medical offices seem to not use these simple, common sense ideas. I am surprised to see people criticising the book so harsh: that's exactly what we need, another health care administrator teaching us how to do our job or how can you compare Disney with a hospital. I think the book successfully demonstrates that health care (and actually any domain that deals with people) can use some of the techniques that Disney is using.

I guess I'm learning one more time that in health care just like in any other field some people will just not get it. And I am sure there are other great books out there that deal with all these issues.

I was amazed to understand why I loved the hospital where I had my first baby and loss, and wasn't impressed by the one where I got home healthy and with a healthy happy baby. The outcome doesn't matter, the people and empathy and caring does. I thought it was more a matter of people cutting us some slack because we were having a loss, vs. being the whiny, healthy woman in labor that is anxious and crazy. You would think that a good outcome should cause a good impression, and a bad outcome would cause anger and need to revenge... not necessarily.

I was happy to also find a useful idea on understanding my anxiety. The author was discussing how when dealing with an angry person, it is important to imagine what the person goes through and empathize with them rather than rationally demonstrating that they have no reason to be angry. This is so right...

I am very proud of being logical and using reason to resolve problems. It is tough on me to realize that when I am anxious and emotional I seem to lose this. Things that seem unresolvable now might seem clear in an hour if my anxiety subsides. I can convince myself how that person did something completely wrong and an hour later just realize that it was just an opinion. So when I talk to someone and I am all emotional and their rational response demonstrates that I am wrong, I feel very bad. I hate myself and get into a spiral of anxiety. If the other person understands that I am emotional and knows that I wouldn't say that under normal circumstances, if the other person lets me know that they get it and I am OK, I feel good, my anxiety dissipates and I can see the world for what it is.

I think that is a lesson for me too: do not argue with people that are obviously emotional, just try to understand where they come from and let them know that you do.

What I would do now if I had my impossible dream

This post is an answer to Paul Levy's invitation to throw out ideas about what can be done to improve safety and quality in hospitals.

Maybe 10 years ago I attended a course in implementing the quality standards ISO 9000. It was a big surprise to me that the course did not seem to teach us methodologies, forms, etc., but was more about finding common sense solutions to enterprise functioning. The most important idea that I learned and kept haunting me ever since that course was: ask the people that do the work to tell you how can their work be easier, how can things work better: they know, just listen to them. It's that simple.

So my answer to Paul is that I have no clue what can they do better, but I know who does: their patients, nurses, doctors and other staff. If someone digs into this collective knowledge and interprets it intelligently, you can find out what you need to do.

I would send a smart analyst (no need of medical knowledge) in the trenches and talk to the patients in the waiting room: ask them what should be changed, what is good, what is bad. Ask the inpatients, ask the nurses, ask the doctors. Don't send a kid with a prewritten questionnaire or survey, the person that does this needs to know what question comes next, needs to know how to interpret the findings. The analyst needs to bought by what he's doing: understand it's importance and believe that he can make a difference.

I would first screen the people I interview by selecting the ones that are good patients, are literate, and that can give reliable feedback.

If you care about patient safety, I would send someone to gently talk to persons that had something bad happen to them. Talk to them even years after the fact. There are some of us that keep searching for answers and would know exactly what doctor/nurse did what mistake and how it can be avoided in the future. They would tell you what hurt them and what helped them heal.
____________

The other day I was reading a pharmacist blog. He was complaining about the old patient that was yelling at him about a problem with the voicemail system. I could understand how he just wanted to do his job - fill in prescriptions. And I felt guilty for all the silly little things, non-medical related that I was telling the nurses and doctors... they don't care about these things, they shouldn't care about these things, but there is nobody else that I see that cares... If I tell the receptionist, she is trained to be nice to me and mind her own business.

Maybe I am a dreamer, but in my ideal world I see an office manager being in the waiting room a lot asking what can be done to improve the patients experience. I think this non-medical oriented person that is empowered to resolve issues that she finds can ease both the patients lives and allow the nurses and doctors to do their job.

There are a lot of patient satisfaction surveys these days... I never found out that I can really give a good feedback in the rigid structure or that my comments had a positive effect on the institution. I personally was seen by more senior doctors and I was treated better because I complained, but that was it. Pretty much like what Paul is describing: if the board only sees green the Board is bored and loses interest. If the only survey result is that we are treating the most critical respondents better, it doesn't make us better overall.
_________

And my conclusion with a sigh: oh, how I'd love to be that analyst!

What works and what doesn't in hospitals - a patient's perspective

Paul, thank you so much for answering my email and your suggestions on how to play with the blog.

My dream started when I was a patient in a hospital and I kept thinking that something can be done to make these people's life better. Here's the story:

My baby was 9 days old and his pediatrician was afraid that he's not gaining enough weight (diagnostic: failure to thrive). He sent us to the hospital to get some blood tests done. If the tests were not good, my baby could have been admitted back in the hospital and be fed through IV.

At the hopital, I ended up in a big waiting room with maybe 50 other (sick) people waiting to go through the admission paperwork. I was told that I will have to wait at least 1 hour to get the paperwork done. I asked if they had a room where I can breastfeed my (hungry) baby. I was told that there isn't one and the person at the desk suggested the restroom.

This is a very nice hospital where I delivered, I was encouraged and helped to breastfeed and I was really satisfiedw with their services while I was in. Their L&D (Labor and Delivery) admission was very friendly: they just sent me to L&D, gave me a bed, and after all the medical stuff was cleared, someone came in with a laptop and got my paperwork. I thought this was very thoughtful and cool.

I imagined that maybe the restrooms are like hotel restrooms, where there would be a quiet, clean room with comfortable chairs. No chance of that... The baby was becoming fussy and I got over my embarasment and everything and started feeding him. (When babies are that small, they need to learn how to feed and you are encouraged to not give them bottles) I imagine that this offended them, because I was called to register within 5 minutes, just 30 minutes after I got in.

Imagine that the waiting room was full of sick people. My drama might have been the least dramatic in that room.

Why can't hospitals do something about this? Why don't they create an electronic check-in like the airlines do? Why don't they have a room for breastfeeding and have that kid with a laptop do our paperwork? If this process works so smoothly for L&D why can't it be made to work for the general admission?

I'm feeling that I can help this somehow and the more I read about the status of helthcare the more I realize that this is one place where I can help, where a difference might help, where something needs to be done.

What is that impossible dream

The impossible dream is getting a job... in a field that I have no qualifications or experience. I would like to work as a hospital administrator... Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston is my hero. I don't want to be CEO or President, but I'd love to help someone like Paul. And I think I have the talent to do it.

This is reaching as high as the sky. This is all so new to me. I am a software developer with no training in medicine or management. I am managing large software projects and I am very good at it. I imagine that the job is the same, but rather than dealing with software, you deal with sick people and people that care for them. I know I need to learn a lot, and this doesn't scare me. I can read, research and learn. What scares me is the interview... oh, no, not the interview.

I'm just starting to see what's under the covers and it is scary. I thought it's all about patients and caring for them, but there's so much else going on: uninsured and universal health plan and HIPPA, and pharma companies, and unions, etc.

But when I was in Romania, working for a leading US software consulting company seemed like reaching for the sky... and I did it. It seems easy now, but it wasn't, and I know I can do it again.

Thank you for hanging out with me while I dig through all this and prepare for THE INTERVIEW.

The Impossible Dream

from MAN OF LA MANCHA (1972)
music by Mitch Leigh and lyrics by Joe Darion

To dream the impossible dream
To fight the unbeatable foe
To bear with unbearable sorrow
To run where the brave dare not go

To right the unrightable wrong
To love pure and chaste from afar
To try when your arms are too weary
To reach the unreachable star

This is my quest
To follow that star
No matter how hopeless
No matter how far

To fight for the right
Without question or pause
To be willing to march into Hell
For a heavenly cause

And I know if I'll only be true
To this glorious quest
That my heart will lie peaceful and calm
When I'm laid to my rest

And the world will be better for this
That one man, scorned and covered with scars
Still strove with his last ounce of courage
To reach the unreachable star


... or, if you prefer French:

http://apo.cmaisonneuve.qc.ca/villanova/emilie/Quete.html