Personal Space.

This has been bugging me for a while now.

In my exam room, there’s a good 4-5 feet distance between where I sit and where the patient sits.  I think it’s a comfortable distance for a conversation. It gives both the patient and myself adequate space. Often patients are bringing in their work bags, suitcases, briefcases, sometimes their groceries even! I’m okay with all of that because there is plenty of room.  But there are a few patients who insist on pulling up their chair right to my desk.  I mean, we are now sitting face to face with a small desk between us. If I crossed my legs, my foot would hit the patient’s shin.   During these encounters I just want to yell out, “Personal space, people!!!!  Personal space!!”

Would you get right up and personal with your  doctor?  It’s a professional encounter – I am not their best friend, but sometimes, I suppose I am their confidante, so I can see how getting close to me physically might be comforting to some.  But it really, really, really bothers me when certain patients do it.  Are they trying to see what I write in their chart?  Are they thinking that the closer they get to me, the more I’ll believe their story?  Frankly, it’s kind of creepy.  And of course, it’s always the patient that rubs me the wrong way to begin with – the patient who comes in monthly for the pain pills, or the one that has fibromyalgia and needs constant hand-holding and reassurance that he doesn’t have some rare degenerative neuromuscular disorder that three neurologists haven’t been able to diagnose.

I need to figure out a way to politely ask these patients to move away from my desk.  I suppose I could use the “patient confidentiality” angle, as I do use electronic record and when I am going from screen to screen, the appointment schedule is visible.

Any advice?

365 days.

1 year. 52 weeks. 365 days. 8,760 hours. 525,600 minutes. 31,536,000 seconds.

My baby boy turns 1 today.

I can’t begin to describe how I feel.  Years ago, I never thought I’d have any children, let alone three.  But then my first child, a daughter, was born and after a difficult year with postpartum depression, as the fog lifted, I had a moment of clarity.  She was almost a year old and I sat with her in the nursery, reading Goodnight Moon as she drank her bottle.  I saw an image in my mind of sitting in that exact chair, surrounded by three children.

One year ago, that picture became a reality.

Happy 1st birthday to my beautiful, beautiful boy.  You have brought me so much joy in the past year.

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Sandwiched.

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The time has come. My parents are getting old.  My dad is going to be 80 next year, my mom is 74 this fall.  Both have been relatively healthy except for a few issues (hypertension and type II diabetes), but that is starting to change.

For as long as I can remember, my dad has suffered with back pain.  I remember him going to chiropractor appointments weekly for what seemed like years for chronic low back pain.  He was told many years ago that there is nothing that can be done about his back pain.  Well, now he’s finally had some imaging, and we saw a surgeon today.  But, unfortunately for my dad, surgery is not an option right now. Even though he has narrowing of his spinal canal (spinal stenosis), it isn’t producing enough leg symptoms to warrant surgery.  Sure, he could have it anyway, to open the canal up, but it may make his back pain worse in the long run.   You see, surgery doesn’t help back pain, it only helps leg symptoms (pain, numbness, tingling, etc).   And in my father’s case, his back pain is far more debilitating than his leg symptoms.  I know he was relieved to hear he wasn’t a candidate for surgery, and I think he finally heard that he needs to get up off his ass and start walking more.  He used to walk all.the.time.  He was very active when I was growing up – he’d go for walks in the evening and play golf in the spring/summer.  But all that gradually changed over the past ten years or so.  As his back pain became more pronounced, so did his excuses for why he couldn’t walk.  Well, that hopefully is about to change.  He was prescribed physiotherapy and exercises to start doing at home.  Even before his appointment, he told me he realized that he’s done nothing to help himself.  I really hope this was the wake up call he so desperately needs.

Today was an eye-opener for myself as well.  It was the first medical appointment I have ever attended with my dad. I stood in the room as his daughter first, but the physician in me knew from the questioning that surgery wasn’t going to happen.  Reading the MRI report is one thing, but hearing the story from the patient, my dad, was quite another.

Back in medical school, or maybe it was residency, I can’t really recall, we learned about the sandwich generation – becoming the caregiver for your own elderly parent while being a parent to one’s own children.

A study published in 2013 found that,

  • 20 per cent: Proportion of employed women and 17 per cent of men in the large survey which are part of the sandwich generation of Canadians.
  • 40 per cent: Portion of workers in the overall survey who report high levels of overload – both at work and at home.
  • 25 to 30 per cent: Portion of caregivers who cope with the pressures of work and family by bringing work home, giving up on sleep and trimming social activities on a daily basis – a response which raises the chance of employee burnout (and grumpy workers).
  • 20 per cent: Portion of male and female employees who are caregivers who turn down promotions because their plate is too full.
  • 63 per cent: Portion of caregivers who report emotional consequences of juggling work and looking after family, which includes stress, anxiety and frustration.

Add all of the above to a caregiver (me) who is also a physician? Oy.

Are you sandwiched?  Have you any advice? I’d love to hear it.

Disclosure.

I hear a lot of pretty crazy stories in my line of work. Sometimes it’s a struggle to believe the patient.  How is it that some people have that much bad luck?

Today has been particularly weird.  I learned today that one of my patients has been stalked by some overseas financial company for the past 15 years.  Apparently, they keep tabs on her in every city she has ever lived.  She has suffered some horrific trauma in her almost 70 years of life, so I’m going to cut her a bit of slack and not rush to have her admitted to the psych ward though sometimes I have to wonder if that’s the right decision.  She admits she’s been living in fear for the past 15 years and is convinced she is still followed.  When I discussed this with my colleague, she pointed out to me that a history of trauma can often lead to a particular state of hypervigilence in an individual.  She is sounding very paranoid, but something has probably triggered a memory of a past trauma and she is projecting that feeling onto something else.  Does that make sense? I am still trying to wrap my head around the entire thing.

My patient isn’t delusional. She’s not making this stuff up, I believe that something happened with this financial organization years ago but how she has interpreted it is likely not what actually happened.  My question is why now? Why is she bringing this up all now?  The answer, after some thought, is actually quite simple.  Her boyfriend of over 10 years abruptly ended their relationship a year ago.  She has been floundering ever since. Overnight her world was turned upside down. She felt abandoned, used and tossed aside.  At first there were a lot of somatic complaints; insomnia, headaches, depressed mood, etc.  She clearly was entering a situational depression.  She would speak tangentially a lot of the time, going back and forth between her early years in Europe and her relationship with her ex-husband, the abuse she suffered at his hand, etc.  It is quite clear that she has spent most of her life surviving one form of abuse or another.  It is truly heartbreaking.

There there’s another woman who disclosed to me that a few years ago she started having flashbacks of horrific beatings at the hand of her mother from the time she was in the playpen.  When I asked what triggered the flashbacks, she broke down and told me she’s been stalked by an individual in the public sector for the past 9 years.  Suddenly, after 7 years of treating this woman, she makes sense to me.  I always felt there was just something missing in her story.  There was a wall that was impenetrable and it has finally started to crumble.  She’s  ready to start dealing with her trauma. Her biggest fear, she told me, was that I wouldn’t believe her story and I would think she was crazy.

And then there was the young male professional who came in because of chest pain.  While taking his history, I asked about drugs of abuse.

Me: “Do you smoke cigarettes?”

Him: “No.”

Me: “Marijuanan?”

Him: “No.”

Me: “Cocaine? Heroine?”

Him: (chuckle) “No.”

Me: “Okay, then let’s check your blood pressure —“

Him: (interrupting) “You didn’t ask about crystal meth.”

Me: “Riiiight.  Okay then … let’s talk about that.”

Wow.  I almost dropped the ball on that one.  He went on to tell me that he started using crystal meth last summer and it was a causal thing, but when the chest pains started it freaked him out and brought him in.  He said he could stop whenever and didn’t feel the need to seek out addiction counselling.  So, I sent him for some routine cardiac testing and he booked a follow up.  (I can tell you that I really struggled not to let my jaw hit the floor when he told me I didn’t ask about crystal meth!)

Fifteen minute appointments are not nearly enough to tackle such disclosures, but this is the nature of family medicine. There’s no telling who is going to have a breakdown, who is going to admit infidelity, drug abuse or sexual deviancy.   In some ways, this is what makes family medicine so much fun.  It never really is boring for very long.

Ten Thoughts Tuesday.

Every morning I go through my WordPress reader and scan through all the blogs that I follow for new content.  Today I came across this post.

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1. I am planning to run home tonight from the office and need to make sure I have a good lunch.  Do I go with a tuna Subway sandwich or get a chicken linguine pasta from one of the local restaurants? I hate making food decisions.

2. My daughter’s school advised us that the bell is at 8:40am.  Why then, at 8:45am, has no bell rung and she’s still in the line up waiting to go in? I’ve never seen a school this disorganized in the morning.

3. My daughter is in grade 1. She’s in a split 1/2 class and says the teacher is focusing on the grade 2 students and they are practicing counting backwards. “It’s easy, Mom.”  I’m not saying my kid is a genius, but if she’s already bored the second week of school, this is going to be a long, long year.

4. I’ve decided to start working another 1/2 day per week. I want to be present for my patients.  I won’t lie, the extra money will be nice

5. I’m so proud of my little boy. He is 3 years old and learning not to suck his thumb during the day. I can see how much he wants to do it, so I know it’s a huge struggle for him not to give in to the temptation.

6. My dad has an appointment with a surgeon next week. I hope he will get some answers and some relief from his chronic pain.

7. I haven’t cross-stitched in almost a week.  I’m starting to feel the itch.

8. I want another coffee, preferable with a splash of Bailey’s.

9. I really have to read the stack of journal articles on my desk.

10. Ten thoughts are hard to come by.