Folie à deux, "a madness shared by two"... not exactly a classic case, but remarkable nontheless...
Working triage today, a patient walks in requesting a medication refill... normally this involves review of a patient's medical record, but given he is a new patient, it would involve patient subjective history, a pharmacy med list, or prior medical records.
A list of common question/answers ensue; with one commonality... see if you can spot it;
"what medication" - not sure
" what for" - not sure
"who prescribed it" - not sure
"where was it prescribed" - not sure
"did you bring a list or the bottles" - no, I lost my backpack which they were in, not sure how or where
"how long have you been off the medication"- (no joke) one hundred weeks
"one hundred weeks is over a year..." - well, at least since August (August was two months ago)
"do you know the month/year today" - got this one spot on!
ok, so we were not getting very far with this questioning. A set of vital signs later ensured that the patient was at least not going to drop in the office, saving us some time for investigation.
"so", I commented "there seem to be a lot of details you aren't clear about, can I ask who helps you remember to take your medication?"
"Sure" he replied "my friend steve or my mom"
Excellent, this NP thinks to herself, I may be able to solve this case yet!
"Can you bring your mom or Steve to the next visit?" I inquire.
"no, they are REALLY crazy" our fairly confused patient comments... ahhhh... Folie à deux
Hopefully our lovely social worker will be able to make heads or tails of the case next week, as I called EVERY major pharmacy in the area, and no record of this kind patient exists.
gotta love the creativity of community health, and the opportunity to occasionally feel like your life is a strange movie that never ceases to somehow entertain...
Monday, October 10, 2011
Wednesday, August 24, 2011
the dreaded refill
the refill process in the USA seems to baffle the majority of community clinic patients (at least in this Latin American community provider's experience). Although I have educated patients in the refill process, helped them call the pharmacy, handed out copious refill instruction sheets, and scheduled visits with social workers and nurses to educate on the refill process, clarifying literacy and other obstacles to refilling much needed medication... the issue still persists. Most recently, I started a campaign with the intake staff, to ask patients if they needed a refill, and instruct them how to 1) call their pharmacy and 2) check if they have a refill available prior to requesting a clinic walk in visit for a refill request.... this seemed to help, for a while, but now the requests are back again.
Some days in health care, I feel like a parrot, repeating the same phrases over and over and over again.... maybe I need to invest in a video production studio and instead of prescribing medication, prescribe an instructional video at the end of each visit... hmmm, that's a thought.
Some days in health care, I feel like a parrot, repeating the same phrases over and over and over again.... maybe I need to invest in a video production studio and instead of prescribing medication, prescribe an instructional video at the end of each visit... hmmm, that's a thought.
Saturday, August 6, 2011
the wolves within
As I have stepped deeply into management/leadership this year in a department which required a great amount of change in order to offer excellent patient care and a positive work environment, I have leaned on the power of story telling. It's amazing how people come together around a common story theme, and can really connect to the meaning of the tale... this is a favorite of my staff;
An old Cherokee is teaching his grandson about life. "A fight is going on inside me," he said to the boy.
"It is a terrible fight and it is between two wolves. One is evil - he is anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego." He continued, "The other is good - he is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion, and faith. The same fight is going on inside you - and inside every other person, too."
The grandson thought about it for a minute and then asked his grandfather, "Which wolf will win?"
The old Cherokee simply replied, "The one you feed
consider; the clinic/hospital/environment in which you work is also the place you are LIVING in... regardless of what you return home to, or what you enjoy after hours. Your words are powerful, in your life, your staff's lives, and your patient's reality.. use them with impeccable caution and create with them the reality you want to live in. It's that easy (and that difficult).
An old Cherokee is teaching his grandson about life. "A fight is going on inside me," he said to the boy.
"It is a terrible fight and it is between two wolves. One is evil - he is anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego." He continued, "The other is good - he is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion, and faith. The same fight is going on inside you - and inside every other person, too."
The grandson thought about it for a minute and then asked his grandfather, "Which wolf will win?"
The old Cherokee simply replied, "The one you feed
consider; the clinic/hospital/environment in which you work is also the place you are LIVING in... regardless of what you return home to, or what you enjoy after hours. Your words are powerful, in your life, your staff's lives, and your patient's reality.. use them with impeccable caution and create with them the reality you want to live in. It's that easy (and that difficult).
calling all critics
what topics/comments do people want to see covered here?
Normally, I wait until an inspiring day to recount long lost stories of community health that come to mind.
Are there topics people prefer me to write about?
Particular questions or situations I can add my experience to?
let me know :)
Onward community health peeps.... you're a rare breed, but the world would never be the same without you!
Normally, I wait until an inspiring day to recount long lost stories of community health that come to mind.
Are there topics people prefer me to write about?
Particular questions or situations I can add my experience to?
let me know :)
Onward community health peeps.... you're a rare breed, but the world would never be the same without you!
Thursday, August 4, 2011
Morado
Morado; Spanish for purple.. the concord hue beloved by many, and a lovely accent for almost any skin tone when use appropriately.... today, While admiring an elderly patient's carefully coiffed lavendar curls I was reminded of the good bad and ugly of the color purple and it's application to community health;
Gentian violet...aka "crystal violet", no, it's not a new urban form of Meth, but an inky dark fluid just this purple side of indigo.... some science geeks (myself included) may remember this lovely substance along with iodine tipping us off to the leakage of starch through a plastic cellulose "baggie" immersed in water during a freshman biology lab (osmosis anyone?)... my patients, on the other hand, apply this willie wonka fluid liberally to ANYTHING that might need curing/disinfecting/fixing/healing/younameit.
I have seen bright purple fingers, patches on limbs, cuts, and burns.. but only one purple penis. Yes, that's right, penis.
I will never ever forget the day that a kind elderly Senor stepped into my office, complaining of a problem with his "parte"... when he presented said "parte" it was stained a bright purple that only meant one of two things; extreme emergency, or case of purple violet dye. "Sir" I asked in spanish "did your penis start off as purple or did you put something on it". I breathed a sigh of relief as he described application of Gentian Violet due to an itchy rash he had experienced the prior week. Return to clinic the following week, and d/c application of lovely purple stain in the meantime revealed classic case of balanitis.... that had been covered up by all shades of glorious purple.
Gentian violet...aka "crystal violet", no, it's not a new urban form of Meth, but an inky dark fluid just this purple side of indigo.... some science geeks (myself included) may remember this lovely substance along with iodine tipping us off to the leakage of starch through a plastic cellulose "baggie" immersed in water during a freshman biology lab (osmosis anyone?)... my patients, on the other hand, apply this willie wonka fluid liberally to ANYTHING that might need curing/disinfecting/fixing/healing/younameit.
I have seen bright purple fingers, patches on limbs, cuts, and burns.. but only one purple penis. Yes, that's right, penis.
I will never ever forget the day that a kind elderly Senor stepped into my office, complaining of a problem with his "parte"... when he presented said "parte" it was stained a bright purple that only meant one of two things; extreme emergency, or case of purple violet dye. "Sir" I asked in spanish "did your penis start off as purple or did you put something on it". I breathed a sigh of relief as he described application of Gentian Violet due to an itchy rash he had experienced the prior week. Return to clinic the following week, and d/c application of lovely purple stain in the meantime revealed classic case of balanitis.... that had been covered up by all shades of glorious purple.
lost in translation
You have to appreciate the Bilingual humor that so often comes with practicing medicine in a community clinic… consider, when one decides upon the final characters for a chinese tramp stamp, before signing on the dotted line, I highly recommend bringing along a friend fluent in Chinese. This can be ever to helpful to prevent accidental life long imprinting of “idiot” or “fatty” instead of the tranquil “longevity” symbol theoretically offered. The same concept is true when purchasing brightly colored T-shirts at a local thrift shop…they may cost $1 in the bargain bin, but unless one is versed in the language imprinted on the T shirt, proceed with caution.
I have fond memories of a lovely Oaxacan patient who came to the clinic in a tight white baby T imprinted with bling bling gold and rhinestones spelling out “That’s right, I’m the bitch” across her tiny chest. This soft spoken Indian woman had NO idea what she was projecting to the world, and my kind MA took a few moments to explain this to her. Crestfallen, the sweet patient opted to leave wearing her shirt inside out. This experience was brought to memory today when I saw an older Hispanic gentleman perusing the halls of the clinic, shade of his sombrero barely obscuring the “Michigan Flip Cup Champ” T shirt he proudly sported. Something tells me this Senor has never played a game of flip cup in his life, but who knows.. maybe he’s developed new skills in a new land?
I have fond memories of a lovely Oaxacan patient who came to the clinic in a tight white baby T imprinted with bling bling gold and rhinestones spelling out “That’s right, I’m the bitch” across her tiny chest. This soft spoken Indian woman had NO idea what she was projecting to the world, and my kind MA took a few moments to explain this to her. Crestfallen, the sweet patient opted to leave wearing her shirt inside out. This experience was brought to memory today when I saw an older Hispanic gentleman perusing the halls of the clinic, shade of his sombrero barely obscuring the “Michigan Flip Cup Champ” T shirt he proudly sported. Something tells me this Senor has never played a game of flip cup in his life, but who knows.. maybe he’s developed new skills in a new land?
Wednesday, June 22, 2011
advice to the neophyte
in response to a recent comment from Neophyte NP as to what I would tell recent grads... especially for a more mature graduate that is completing her clinical soon.
here goes a stream of consciousness reply to that post (as I cannot apparently reply with anything longer than 4000 characters, i will post it here!)
basic things that come to mind;
- choose your own clinicals... focus on places/jobs that mirror those you would like to consider (and if you're not sure, then choose a variety), finding your own preceptors ensures that you have a placement where you learn from your preceptor, and experience the work environment/patient set that you will need experience with for the future. Much of what you learn in school is learned in clinical, make the most of it. A tip: talk with students that are one year ahead of you (or one semester) and ask about their clinicals... find preceptors that other students love and ask in advance to be recommended to work with that preceptor next semester (I found most of my precptors this way)... another idea; talk with professors you highly respect (well in advance) and ask to do a clinical rotation with them (be persistent!). It's a good idea to either work a BUNCH of days at one site in a row, or to spread your clinical over regular days at the same site... thus you can either get a feel for a LOT of work flow at one time, or get to follow up with your own patient "panel" during clinical. Consider daily topics with your preceptor... choose common disease topics, pediatric physical age sets, or the like, and discuss for 15 minutes over lunch... often, you can choose the topics in advance, and then you can present the topic to your preceptor over lunch, this gives them a chance to add their two cents at the end, and to review their own knowledge base as well! I'm a proponent of the idea of NP residency, but until this occurs, chica, your clinicals are your residency before the trial by fire begins on your first day, so make them your own, it's your last chance to control where you work/what you do!
good sites for preceptorships;
- community clinics
- planned parenthood
- other sites where your friends have really enjoyed their clinicals
- specialty sites you might consider working in the future.. give it a try before you commit!
other things to remember... you are 48, I consider experience to be a good thing (and it freaks the patients out less.... after all, I'm 31, but patients often ask if I'm 19, not exactly ensuing confidence from the first visit, lol). When you are new, you will have to ask a lot of questions/look up a lot of stuff/ take a lot of NSAIDS for the headaches this will cause (lol, no seriously....)... each day, you will answer another question that you will then know the answer to the next day... after a while at the job, you will be a pro (really, you will) and you won't have to ask those same questiona again, you will remember the basics, and look up the rest, I promise!
Funding; consider the NHSC (National Health Service Corps) their loan repayment program is way easier to get approved than the scholarship program, and it's a great way to get your feet wet in the community, while getting loans paid! Also, community clinics are often more eager to hire NPs right out of school (even before that pesky furnishing license has been earned!).
things to learn now; schools don't often teach about medical coding/billing and proper paperwork/NP practice protocols for clinical work. Clinics REALLY don't know about them... so take the opportunity to rack the professorial brains and preceptor opportunities available to you now (learn how to fill out an encounter form/super bill, play with electronic health records), ask your professors how to write your own standardized procedures, and what your state regulations are... trust me, most clinics and clinicians don't know how to write paperwork for legal NP practice, and most med students don't know HOW to fill out a billing form (even though doing it wrong actually constitutes fraud... and frankly, it's our bread and butter to keep the doors open).
well... phew, those were my initial thoughts that came to mind under the "what I wish I had known" category.
Good luck neophyte, soon you'll be an oak tree :)
here goes a stream of consciousness reply to that post (as I cannot apparently reply with anything longer than 4000 characters, i will post it here!)
basic things that come to mind;
- choose your own clinicals... focus on places/jobs that mirror those you would like to consider (and if you're not sure, then choose a variety), finding your own preceptors ensures that you have a placement where you learn from your preceptor, and experience the work environment/patient set that you will need experience with for the future. Much of what you learn in school is learned in clinical, make the most of it. A tip: talk with students that are one year ahead of you (or one semester) and ask about their clinicals... find preceptors that other students love and ask in advance to be recommended to work with that preceptor next semester (I found most of my precptors this way)... another idea; talk with professors you highly respect (well in advance) and ask to do a clinical rotation with them (be persistent!). It's a good idea to either work a BUNCH of days at one site in a row, or to spread your clinical over regular days at the same site... thus you can either get a feel for a LOT of work flow at one time, or get to follow up with your own patient "panel" during clinical. Consider daily topics with your preceptor... choose common disease topics, pediatric physical age sets, or the like, and discuss for 15 minutes over lunch... often, you can choose the topics in advance, and then you can present the topic to your preceptor over lunch, this gives them a chance to add their two cents at the end, and to review their own knowledge base as well! I'm a proponent of the idea of NP residency, but until this occurs, chica, your clinicals are your residency before the trial by fire begins on your first day, so make them your own, it's your last chance to control where you work/what you do!
good sites for preceptorships;
- community clinics
- planned parenthood
- other sites where your friends have really enjoyed their clinicals
- specialty sites you might consider working in the future.. give it a try before you commit!
other things to remember... you are 48, I consider experience to be a good thing (and it freaks the patients out less.... after all, I'm 31, but patients often ask if I'm 19, not exactly ensuing confidence from the first visit, lol). When you are new, you will have to ask a lot of questions/look up a lot of stuff/ take a lot of NSAIDS for the headaches this will cause (lol, no seriously....)... each day, you will answer another question that you will then know the answer to the next day... after a while at the job, you will be a pro (really, you will) and you won't have to ask those same questiona again, you will remember the basics, and look up the rest, I promise!
Funding; consider the NHSC (National Health Service Corps) their loan repayment program is way easier to get approved than the scholarship program, and it's a great way to get your feet wet in the community, while getting loans paid! Also, community clinics are often more eager to hire NPs right out of school (even before that pesky furnishing license has been earned!).
things to learn now; schools don't often teach about medical coding/billing and proper paperwork/NP practice protocols for clinical work. Clinics REALLY don't know about them... so take the opportunity to rack the professorial brains and preceptor opportunities available to you now (learn how to fill out an encounter form/super bill, play with electronic health records), ask your professors how to write your own standardized procedures, and what your state regulations are... trust me, most clinics and clinicians don't know how to write paperwork for legal NP practice, and most med students don't know HOW to fill out a billing form (even though doing it wrong actually constitutes fraud... and frankly, it's our bread and butter to keep the doors open).
well... phew, those were my initial thoughts that came to mind under the "what I wish I had known" category.
Good luck neophyte, soon you'll be an oak tree :)
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