It has been a difficult year for us. I have been told over a hundred times that building a home is the hardest time a married couple will have, and although Brian and I have not slept in separate rooms or had any terrible fights it has been fretful at times. Add to that my decision to change jobs and you can imaging how rough this has been. So, as someone who has known The Lord from a young age this has been a year of trials for me.

Now first off, I am not – nor do I ever stress to be – anything close to perfect. I use curse words much more often than I should. I watch movies that I shouldn’t. I even catch myself gossiping when I know that is wrong. I am driven and expect everyone I work with to work as hard and with as much drive as I do, because people’s lives depend on it. So, like David before The Lord in Psalms

Have mercy upon me, O God, according to thy loving kindness: according unto the multitude of thy tender mercies blot out my transgressions. Wash me throughly from mine iniquity, and cleanse me from my sin. For I acknowledge my transgressions: and my sin is ever before me.
Psalms 51:1-3 KJV

And, if you ask those that know me I am sure they can tell you many more of my sins and faults, but as a child of a loving father in faith I am not afraid to admit them and ask for help. Being adult enough to admit these faults has been a new thing for me this year. Also, these admissions have helped me in my struggle with our religion. Now, most people would question me here on what is the difference between faith and religion, as they should. See, I was raised in a different religion than the church where I now worship, but this is the adult intelligent choice I have made for my family. So, I struggle with minor points of religious doctrine.

But dealing as a doctor with people of all faith and of none, and of all religions and of none, I cannot afford to be narrow minded in how I interact with patients in regards to how they relay their concerns of faith. Whether I am speaking with an elderly patient who has enough faith and comfort in her religion to speak about advance care plans with the peace of one facing the end of her life as one going to meet an old friend who promises a release from pain and suffering, to the conversation with a grieving family member asking “why me – Why would God take this thing, or person, or whatever – what did I do to deserve this?” Speaking with patients about Christian faith is at least something I have some background in. Understanding the peace that can pass understanding, and personally being able to relay that knowing the answer to “why God” may never come and may be not for us as children of God to know.

But where I struggle as a physician, dealing with crisis of faith even in my new job, when I “loose my heart of a servant” is when I am trying to help families of different faith ideologies or of no faith at all. See, I have my faith, but the biggest part of my job is not forcing my faith, morals, or any aspect of my personal belief systems onto a patient. So, not knowing anything about Wicca (for example) or the religious rites of Native American tribes, how do I not offend by inserting my Christian beliefs? How do you help when you don’t where know to start?

Wanting to help and be a supportive physician, whether it’s as a family doctor of ten years or your emergency room doctor of twenty minutes – I want to think that there is a way and a time for concerns for a physician’s faith and for that of their patients.

I realize that patient’s faith may not be as big an issue in other parts of the country but here in Tennessee, where I live, faith is a huge part of patient’s lives. There are still families that don’t speak to certain members over issues of faith, issues of sexuality, or even issues of different religions. I wish I had had more formal training in how to handle these issues that are so deeply personal to my patient’s lives, so I felt more at home in this area, but I am glad that through my own faith in my Lord I am finally able to try to handle this complex minefield of faith.

Well, for those of you that have read my blog, you realize that I have been remarkably silent for the last two months. It’s not that I have run out of things to say. It’s just that with building the house, dealing with sick kids, the fall sick season, and a difficult personal decision,I have not really known how to put my feelings in writing.

As my preacher said in a recent sermon, everything changes. And 2012 has been a real year of change for me. Brian and I have been building a home for the last year. Ella has begun with 4-H. My youngest child started to school. My brother and I are mending fences. But the real change is the new job opportunity that was unexpected in my life. As of January 2013, I will no longer have my own primary care practice, but rather be a full time emergency room physician at our local hospital.

I want to set the record strait because I know there has been a lot said about this decision. I have been blessed in my practice. I work in a wonderful office with an awesome staff and great fellow physicians. The last eight years in my own practice have been and true gift from God in the relationships that I have been allowed to develop. Individuals and families have opened their lives to me and allowed me to be a part of a very special relationships, and I can only hope that I have been able to help these families and patients through medical, physical, or psychological issues. My role as a family physician in my home town has truly been an honor.

However, this role has also had a personal cost. As most of you know that read this blog, I am a mother of three small children. They are nine, seven, and four. What you may not know is I went back to work with my younger two children when they were only three weeks old. I returned to work after a Hysterectomy in three weeks as well. I miss school plays, party’s, and weekend family get togethers. And this is ok, this is part of my job. There can be days where I may not even see my kids. But, this year, I was offered a new job, a full time job in the emergency room that has shift work with no call. So, despite how much I knew it would hurt my patient’s, in order to be a better Mom, I took the job.

I want to thank each and every person who has trusted me with their care over the years. I want to thank my fellow physicians for their support and their knowledge, and their support during my own personal illnesses. I hope that everyone can understand that this was not a choice that I was seeking but rather a choice that will be a better change for me as a mother.

Its been a few days since I had time to sit down a blog. Life somehow seems to be determined to intrude in my social media communications efforts. School has gotten started. (We are already two science projects completed in the fourth grade -making a cell and completing a habitat. Those tadpoles the kids “rescued” from the pool earlier this spring came in handy after all.)

But I digress, I wanted to write about a missed opportunity I had for health care with a patient the other day. And it’s not what you think. I didn’t forget to write their blood pressure medicine, check their A1C (a blood test that tells a doctor how well a diabetics blood sugar has been controlled for the last three months) or forget to make sure that they were up to date on their screening colonoscopy. I forgot to sit down and take a moment in prayer with them.

Faith in medicine is far to often overlooked by most doctors, but held in deep regards by most of our patients. Whether that faith is Jewish, Muslim, Christian, Wiccan or one of the many other faiths held dear by our patients. We are not taught in medical school how to bridge this gap between the science of medicine and the faith of both ourselves and our patients.

Now, many doctors and healthcare providers have a great difficulty when it comes to dealing with faith. Dealing with large urban populations with diverse faiths and beliefs is challenging to say the least. Here in the middle of nowhere, I mainly deal with the many Protestant religious beliefs. The most challenging medically is that of the Jehovah’s witnesses but even they and I share a common ground in most things, just not in transfusions.

But getting back to my missed opportunity in healthcare, I was ask as I walked out of a room to pray for a patient’s ailing brother. I promised I would, but in the rush of a clinic day and my newness in thinking of faith as part of my job as a family doc, I walked on into the next room. It was only later at night as I finished my daily bible reading that I felt that I had missed an important part of that patient encounter. No, I will ever be able to bill or code for “prayer” and may even be counseled against thinking along these lines, but given my own beliefs in a higher spiritual power, I think I will watch for these faith based medical opportunities.

I am not naive enough to think that every physician will suddenly be comfortable enough in their own spiritual journey to counsel with their patients, but I think it can offer a comfort to patients when sometimes there is little else medicine can offer.

“Mommy, what was that about?” “Mommy, why were you telling them to restr, restra, and what does that r word mean?” “Mommy, why did the nurse need to call the family?” “Mommy, will you miss church?”

Now, my daughters have lived with me being on call their entire lives and can probably explain HIPPA better than many attorneys. They just put their ear buds in and don’t ask any more. But the four year old has not learned privacy as defined by HIPPA and the federal government. So, even though I spent the rest of the ride to church explaining HIPPA, I am still not certain he understood.

That story brought to mind why I don’t blog very much about medical issues. Its not that I don’t have concerns about the state of modern medicine, worries about the future of health care, or stories that would make the most stone hearted person cry with concern over the fate of America’s health, its just I get started then I worry where does HIPPA start and I stop.

So, as I tried to explain to my 4 year old, HIPPA is not a HIPPO – it is a set of legal rules that every doctor, well actually everyone that works in healthcare, must follow.

Simply put, it means that in NO WAY can we violate in speak, written articles, text messages, social media, email a patients right to privacy.

Is this always the easiest thing to work under, no. Is it a good idea in theory, yes. But, for example, you are traveling, miles away from home. You are in an accident and end up in a critical care unit with no way to declare who is your loved one and who is legally HIPPA compliant. Technically, the medical team should not speak with anyone over the phone about your condition.
Not your spouse or children, no one, because after all, how do they know who is on the other end of the phone. That seems a little silly, but at least once a week in my rural practice, I am put in a situation on the phone with a family member far away wanting to know how their parent is and I have no way to validate their identify, so what to do… I have to abide by HIPPA, which can lead to very angry patients families. Or here is another situation, what if an elderly demented patient suddenly decides that their doctor can’t tell anyone about their health issues. Now what do you tell the family when they ask about Mom’s health when you make rounds at the hospital?

So, even though I am glad we have laws to protect patient’s rights to privacy… sometimes HIPPA becomes a HIPPO for me to deal with.

Family medicine in a rural community has been my lifetime goal since before I can remember understanding what a goal meant. But, I have had a really hard time blogging about medicine and medical issues. I have a treasure trove of stories about my interactions with patients but due to HIPPA (the patient privacy law) I am not sure how to write about them. So, in answering a challenge from a friend to write more about medicine I am writing today about some of the challenges I face in rural Tennessee as a doctor.

First off I’d like to state that up until a recent trip to Washington, D. C., I thought I worked in a rural area. Then I met some ranch farm mom’s from Utah, Wyoming, and Arizona. These farm mom’s live on homes 80 miles from towns. They do things like buying homes in town when their kids start high school just so their children can play sports. They drive 2 hours to take their children to town to see a pediatric doctor, as a twitter friend in Montana told me. So, now with a better appreciation of my not so rural medicine practice, let me tell you a few of my trials.

1: The inefficiency of Tennessee’s TennCare (it’s our states version of Medicaid) program as it relates to rural healthcare.

In my county, about half to 2/3 of my patients at any given time are on TennCare, which is fine. We live in a poor county and have been hit hard by the “economic downturn”. (I still have patients that cannot read and write/our schools still graduate children that read at maybe 8th grade levels)

So, my staff and I spend a lot of our time dealing with TennCare. I call this a problem because they constantly change their medicine formulary. This means that every six months or so, someone decides what medicines are paired for and the list changes with NO warning. What this means to patients is medicines that they have been on may no longer be covered. They have to either come back in or call and get their medicine changed.

Also, TennCare pays specialist so slowly or so poorly that many specialist will not see these patients. In larger urban areas this may not be a problem for doctors because even if only 10 orthopedist see TennCare patients in a ten mile radius that’s not that far in Nashville. But in my area, we often have to send patients over 100 miles in search of a specialist that will see them.

Also, my nursing staff waste hours and hours each week, seeking “prior approvals” from TennCare. Now I am not disputing that there is a lot of wastefulness in medicine and over utilization of testing (mostly to prevent lawsuits), but in rural Tennessee there are times I need a more efficient way to get an emergent test instead of waiting 2-7 days. Yes, the Internet system that TennCare put into place last year has helped tremendously, but there are always emergencies when a physician needs an answer right now.

I have a perfect example, I had a small TennCare patient under two years old who fell and had significant head injury in my office. I needed a head CT. We called TennCare seeking emergent prior authorization and were told to either send the child to the Emergency room and let them do the scan or admit the child to the hospital and scan her head that way because there was no way that we would ever be able to get an approval in less than 2 days. And you wonder why the TennCare budget is out of control. It took me over 30 minutes to get a supervisor on the phone to get my test that day. The patient ended up being fine.

2: This past year Medicare changed the rules for Home health patients requiring a face to face visit with in 90 days of initiating home health. That sounds very reasonable. But in rural Tennessee, some of my home health patients have been at home, in their beds for the last 5 years. I would love to know how their families were supposed to get them to my office for a face to face visit? This is an issue in urban areas too. Unless a provider makes house calls, I am not aware of a way to work around this. Most of these “face to face visits” can be done when a patient leaves the hospital, but for those truly home bound patients I ended up making house calls.

3: My last rural medicine difficulty for the day, has been the difficulty in bringing 21rst century medicine into a very rural world. I don’t just mean medical health records, although that has been fun. I have a few elderly patients who don’t like me to bring the computer into the exam room. They are afraid I am playing a “game or something”. But even issues like trying to explain evidence based medicine about issues like not needing antibiotics for sinus infections or how narcotics are not the best treatment options for chronic lower back pain.

Well, I hope this give you a little insight into some of my challenges. I love my job and my patients. I have. Even blessed to be a part of their lives now for going on nine years and looking forward to many more. Yes, many things in the structure of medicine could be better, but what does not kill us only makes us stronger.

The Doctor, by Sir Luke Fildes (1891) (Photo credit: Wikipedia)

Well, this has been my call weekend. It has been not to bad. Friday, I worked in our Emergency Room for a twelve hour shift, and then the remain two mornings I have gone in and made hospital rounds for the groups inpatients. Add, picking up Ella from camp, making it to Sunday night service, feeding the cattle in between rain showers on Saturday, picking up around the house, and a few other things and you get the drift of my weekend.

This weekend like every weekend I am on call, at some point I have to face a life and death situation. That brings me to my topic, a difficult conversation. There is nothing harder on me as a doctor then having to walk into a room for a patient that I am not their regular doctor and have to talk with them about end of life care. But, it seems that every weekend, it is a conversation that keeps repeating.

I have faced this conversation from both sides of the health care coin. When my grandmother was wasting away from dementia, she eventually forgot how to eat and drink, along with me and everything else, I had to make the end of life decisions about her health care. But, unlike most of the families I talk too, my grandmother had made a living will with very specific end of life care plans for me to follow. Even with her wishes spelled out, watching her waste away was never easy. I still wonder at times did I do the right thing.

I don’t have the answers for ever patient as they face the end of their time on this planet. Nor do I think that as the doctor, should I have the answers.  I can offer guidance, medical facts and statics, and information about a particular medical case.  I can pray, cry, listen to tales of better times or hopes for a reunion among angels.  I can grieve with families uncertain of a loved ones fate.  But, the only thing I can guarantee as a physician, who has had a lot of end of life talks with a lot of families and patients, the only way to guarantee your wishes is to write them out, tell your family, have a living will, and talk to your doctor in advance. Believe me, it is better to have some planning months to years in advance for end of life, rather than waiting till an emergency arrives in a hospital setting where you may not be able to speak for your self.  And if your state is like mine, if you have no stated end of life care plan, then we as health care providers must do everything within our power to resuscitate you.

Having a good working relationship with your doctor means you can talk about all aspects of your health, even those hard discussions that none of us want to think about, the last plan. When a doctor broaches the subject of do not resuscitate (DNR), that conversation can be as hard for them as it is for the family. Also, DNR does not mean not to treat, it just means that if death occurs we do not try to reverse the occurrence. An easier way to think about the DNR is to Allow Natural Death (AND). To be able to make health care decisions for another family member you must either be their closest living relative or have a durable medical power of attorney. (And remember, durable medical POA only come into play, if the patient in question is no longer able to make medical decisions for themselves.)

Related articles

• To resuscitate or not to resuscitate: is that the right question? (boston.com)
• Volatile issues surrounding end-of-life care remain unaddressed (buffalonews.com)
• The Takeaway: Hospices Diversify End-of-Life Care to Suit Boomers (aarp.org)

Its been a long week at work and I have not have any time to be on the farm or do much with agriculture this week and you can guess by the title and pictures with this blog that my work week has not gone so well. It is very hard for me to see the damage done to families when they loose family members to drug and alcohol addiction. It used to be maybe one family in five had a problem with some type of addiction. Now, here in upper rural Tennessee, with little improvement from the hard economic downturn, drugs and alcohol are the easy way out.

Now, it is far too common for children not to know where, or sometime who, their parents are. These children are being raised by grandparents, Aunts/Uncles, or Cousins if they are lucky, and the state foster system if they are not. These are the 12-15 year olds that smoke, have drank at parties till they are drunk, and more than likely have tried drugs and sexual activity.

In my job, I see the tired, lost looks on the faces of the older family members, as they sit and wait outside of critical care waiting rooms and emergency departments more times than they can remember. Waiting once more to hear if their grown child has taken one to many pills, or mixed the wrong pills with some new drug for a high that may end up being their last. I see the faces of the not so elderly family members, aging days and years in a matter of minutes, as they too sit and wait is the same drab waiting rooms, for news about their teen children, brought in by the local police, or worse, found “unresponsive” at a party. But, of all these faces, the ones that remain in my mind, and haunt my sleep, are the faces that remain frozen in ageless grief, when they realize that after this night, they will fight no more with their loved ones addiction, and there will be no more need to wait, because this night, their love one became another statistic to be quoted in blogs and newspaper stories about the “problem with prescription drugs” in America.

For me, this blog post will always be way too personal. Even though, there are pictures and graphs in this post, they are simply here to remind me of the faces of cases that I cannot share, but will never forget. Families, who have lost a very personal battle, in a very public war with prescription drug abuse. I hope that the next time you are thinking about this topic you remember that somewhere there is a family that stood around a lonely grave, burying someone that meant all the world to their family.

I guess, I am just feeling morbid over these thoughts. And I will freely admit, I don’t understand the mindset of addiction very well. (I mean, yes, as a physician, I understand the pathophysiology of addiction as well as any other physician does, but as a human being I just don’t get it!)
I don’t understand how being blasted drunk or so high you cannot think clearly is in any way a good thing. And as a Mother, I will never ever understand how there is any drug, drink, or substance on this Earth more important to you than being able to care for and protect your children.

This past week, the TV networks were all talking about the medical study showing that taking vitamins will kill you… Now, I know that is not what that study said, but that is what most of my patients heard. Even one of my nurses was asking me if she should stop taking her multivitamins.

The vitamin study was actually designed to see if there were links between a number of things and earlier death. There was a link note in earlier death in women ages 55-65 if they took a multivitamin, but this was not a CAUSE and EFFECT study. Look at this from another angle, there could be a study done tomorrow that shows a link between eating dinner at a restaurant that serves alcohol and car wrecks, but that does not mean that eating at Outback/Red Lobster/etc will cause you to have a car wreck.

This type of study was never designed to find the cause just to note associations between incidences. This fact was so over looked by the modern news media.

Then, there are times when medicines may be deemed unsafe after a period of regular use, or have new restrictions on use. Simvastatin is a perfect example. When medicines are approved by the FDA, the drug manufacture has to prevent evidence of the medicines safety to the FDA. This means humane trials, usually double blinded placebo controlled studies. (That is the type of study where neither the doctor or patient knows if the patient is receiving the drug in question. This is the best type of study to remove most bias.) So, in human trials the drug company has to show safety data – this can be from a study on 100 people for 6 weeks to thousands of patients data for years.

These are good steps to ensure safety, however, as with simvastatin or even vioxx, once you start writing these meds for a couple of million people, doctors find out more about the medicines safety. So now simvastatin is recommended to be dosed under 40mg and under 20mg if a patient takes certain heart medicines, and vioxx was taken off the shelves all together.

I admit this is a flawed system, filled with internal bias, but it is the best we have for now. So, I implore you, the next time Katie Courick is telling you about how bad a medicine is, check her sources and get ALL the facts.

As to the link between earlier death and vitamin use, I suspect it is because people who take vitamins are more concerned with their health because of established illness, thus this represents a group more likely to die anyway. As for me, I will keep taking my vitamins till I hear of a definite causal link in a study, not just a hyped up association study.

Indulge me a moment, I want to teach you a little about medical training before I talk to you about the glories and trials of being a small town country doc. Unfortunately due to the attitudes of traditional medical training, country docs are becoming an endangered species. I want you to walk you through what it takes to become a physician in America. First, you have to go through college and earn either a degree or enough credits to earn early entry and you must get high marks on your MCAT (medical college aptitude test). Most colleges are in cities of some size. Then comes medical school, this will definitely be in a major city. That is four more years spent in a metropolitan area. Finally, you have to choose a residency. Residency training varies depending on what kind of doctor you want to be, from three years for Family Medicine to eight years for Neurosurgery. Traditionally, this training also takes place in a major city. So, now this young driven future doctor has spent the formative years of their early adult life in a city.

While you are in medical school, the future doctors face many challenges and prejudices. I trained ten years ago, but what I hear from students today still confirms that many medical schools have a bias against the training of doctors fit to work in rural America. These specialties would be the primary care specialties: Internal Medicine, Family Medicine, general pediatrics, and General Surgery. (I would like to make an aside here and let you know that Family Medicine is a board certified specialty and is NOT a General Practice doctor.) Even now, at medical meetings I am often quizzed on why I chose family medicine with its long hours and lesser financial payments. Even now, many of the forms I fill out, insurance paperwork I do, or even documenting the numerous phone calls and email request offer no financial payment.

The crisis facing primary care in America is not dissimilar to the aging crisis facing America’s farmers but that is a different soap box.

But, I would like to take a moment to give some thoughts on why I LOVE being a doctor in a small town. I was running tonight and got a “Hey, doc” from a patient. I can leave my kids at the ballpark and not worry overly much cause they know or are related to most everyone there. If I forget a check when I am getting my hair done, they know I am good for it. I am known and liked at church, the grocery store, and even Walmart 30 miles away. My patients are my Facebook friends, my blog readers, and people that I am proud to be involved in their lives. I help them through illness, family crisis, and personal achievements.

But, what about the bad parts about medicine in a small town. Well, I guess some people would not like having so many people know what their every move is, but I have been truly blessed to find a balance between private family time and community involvement. I guess, some would also not like the lack of “things to do” and “cultural enrichment”, but I would say those people have never walked barefoot in the fields and spent a lazy afternoon teaching their kids to catch brim in a pond. There is true achievement in baiting your own hook. I also deal with my patients, wanting to go to a “specialist” in a “city”. At first when I moved home, that bothered me. After all, I had just spent 10 years learning how to treat illness and disease and now I am supposed to send people off to a city because why… But now, I take that in stride too. I can understand that there is a time and a place for me to treat illness, a time and a place to respect patient’s request to seek another opinion, and even a time to tell patient’s that it is in their best interest to seek another opinion. (I have no problem knowing what I do and don’t know and what we can and cannot treat in my hometown)

So, by living in my hometown for the last 7 years, I have learned many life lessons from my patients. I have learned courage and faith in the face of a terminal illness. I have learned humor makes everything better at times and at times nothing is better than crying with the patient and families who have made me a part of their lives. I have learned humility and willingness to seek other opinions. I have learned that a temper and pitching fits never helps patient care or staff relations. I have learned that mutual respect, even when we disagree, is a better policy than trying to always be right.

Most of all I have been blessed to learn patience from a wonder group of patients and health care providers who have been willing to learn from me and teach me at the same time. Short of being a Mom, there is nothing else that I am more proud of than being a “country doc”.

So in a nutshell…

People are made of organs and organs are made of cells. Those cells have a certain lifespan programmed into them, and when something happens either from external stimulus i.e.smoking/radiation/asbestosis exposure or internal cell reasons i.e genetics any cell in your body can forget how to die. Basically, anything that may cause a normal body cell to develop abnormally potentially can cause cancer. When this preprogrammed cell death fails to happen a cancer cell is made. Now this is actually thought to happen all the time in our bodies, so why don’t more people have cancer? Because our body has immune cells that go around and fight off these altered cells. When the cancer cells (the cells that have forgotten when to die) overtake the immune system and keep growing, those growing groups of cells are now a a cancerous tumor.

There are many terms that doctors use to describe cancer and tumors: carcinoma, sarcoma, leukemia, malignent, metastatic… and each one has a very different meaning.

Carcinoma: Cancer that begins in the skin or in tissues that line or cover body organs

Sarcoma: Cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue

Leukemia: Cancer that starts in blood-forming tissue such as the bone marrow and causes large numbers of abnormal blood cells to be produced and enter the blood

Lymphoma/Myeloma: Cancers that begin in the cells of the immune system

Metastatic: Cancer that has sread either by lymph nodes or blood from its original site

Malignent: Another medical word for cancer

The most commen question I get in the office is – “Doc, I want a blood test to tell me if I have cancer…” Given the about explaination you can see the problem in this. There is no one blood test for eye cells, brain cells, liver cells, and gut cells. There are certain tumor markers for certain types of cancer, like CEA (Carcinoembryonic Antigen) which is present in Large Colon Cancers, some ovarian cancers, some pancreatic cancers, some breast cancers, and some lung cancers. But this test would be negative in a patient with Melanoma (an aggressive form of skin cancer).

So, what are the most commen types of cancers that affect us here in the U.S.?

Cancer type Estimated new cases Estimated deaths
Bladder 70,530 14,680
Breast 207,090 39,840
Breast(male) 1,970 390
Colon&rectal 142,570 51,370
Endometrial 43,470 7,950
Kidney 53,581 11,997
Leukemia 43,050 21,840
Lung 222,520 157,300
Melanoma 68,130 8,700
Non-Hodgkin lymphoma 65,540 20,210
Pancreatic 43,140 36,800
Prostate 217,730 32,050
Thyroid 44,670 1,690

The three most common cancers in men, women and children in the U.S. are as follows:

•Men: Prostate, lung, and colorectal

•Women: Breast, colorectal, and lung

•Children: Leukemia, brain tumors, and lymphoma

Cancer affects us all. It has no preferance to race, sex, or age. It will affect, sicken, and sometimes kill the very young to the very old. I have seen it do all this and more.

What I hoped to provide in this article is simple commen sense terms to exlpain what is often a scarey and life altering diagnosis.

If you don’t understand what your doctor told you, ask again, and keep asking until you do. Don’t agree to test you don’t understand. It is your body and you need to know what the risk is and potential benifit from each and every test or treatment that anyone wants to run on you.

And lastly, sometimes it is the bitter truth that Cancer kills. Don’t be afraid to ask for help with spritual counseling whatever your faith may be. Make sure you understand what kind of treatment odds you are dealing with from the doctors. So many times as a family doctor, I get the letter from the Oncologist explaining the palliative therapy (therapy to just make symptoms better not to treat or cure the disease) that my patient is in, and then will see that patient who tells me that the cancer doc says it looks good for them. I don’t think anyone is telling falsehoods, I think that there is a lot of selective hearing that goes on when talking about cancer. And even more selective hearing happens, when a doctor starts talking about potential end of life.

Never ever be afraid of big medical terms, sometimes you may find that the doctor is just as uncomfortable with talking about cancer as you are. My personal losses with this disease are two of the best grandparents you could ever have, and watching them face this illness in two very different ways and still die still hurts. I can see the faces of the patients that I have lost to this illness, and it makes me angry, but then it also makes me want to make sure that my patients understand to the best of their ability what they are facing.

Overall, I think one of the biggest downfalls of my profession is doctors spend 8 years or more learning to talk in arcacic terms and in language way above the average patients understanding. Then, when we as MD’s are out of school, we forget that not everyone talks like we do.

Case in point… I was giving a community talk on heart disease and the Cardiolgist that was talking with me got ask to explain Congestive Heart Failure. He looked at his watch and said there is no possible way to explain that in the 5 minutes we have left and ask for the next question. Seeing the womens crestfallen face, I ask the cardiologist if I could try to explain heart failure to her. He looked at me funny and said to try. I did it in 4 words… “your pump (heart) don’t work”. He was astounded and she understood. The Cardiologist later told me that he never thought to take such a simple approach to the explaination.

So, if God forbid, you or a love one ever face this terrible disease in any form, I hope this will help. Remember that it is OK to be overwhelmed when you are first told and your doctor should realize that you may need to hear this shocking news more than once. Make sure you understand what you are risking and gaining by various test and treatments, and make sure that you understand what your doctors treatment goal is. Often doctors and patients are worlds apart on this, i.e treating for a cure verses treating for remission of symptoms (palliation). Make sure you understand the diagnosis, write it down if you have to. And lastly, remember that your doctor brings their past into this as well, and may have as hard of time with this diagnosis as you do.

So much of the language used by health professionals is alienating and even frightening, and it belies troubling attitudes towards mothering and mothers. Chemical pregnancy, blighted ovum, incompetent cervix, boggy uterus, hostile mucous – these are not respectful phrases. They are frightening and judgemental and downright nasty about women’s bodies and the delicate but deliciously natural art of reproduction. A labouring woman may be told she is only five centimetres dilated, or that she is failing to progress. And no bloody wonder, since it’s hard to surrender to hormonal surges and do the work of labour when people in white coats keep pursing their lips at you and saying things that sound suspiciously like a Year 9 PE report. A new mother might again hear that word failing in relation to her efforts to raise a satisfactorily plump baby, if her child doesn’t fit the numerical definition of thrive on weigh-in day.

Those who try to cushion the apparently terrifying reality of birthing and mothering with euphemisms can make matters even worse. You’re going to feel a little tingle now is never a true statement! I’m just going to give you a little snip is a nice neat lie designed to trick us into thinking that an episiotomy is just a nice, neat thing that makes all our lives easier. (The most insidious and disempowering euphemism of all, delivery, probably warrants a whole essay of its own.)

And then there are the popular euphemisms used to avoid speaking the truth about our bodies. The ones that keep us all in the dark about the natural physicality of mothering. My mother-in-law can’t bring herself to say breast. To ask about breastfeeding, she must say ‘are you still feeding her yourself?’ I feel like telling her that no, I’ve decided to employ a wetnurse. Bean’s Great-Grandmother has remarked that I do a good job ‘being a cow’, as if it is somehow more natural for cows to be provide milk for babies than for humans to do it ourselves. As if cows invented lactation.

Those last examples are more humorous than worrying. I’m not about to demand better communication from my in-laws – I figure it comes with the territory. But I’d be happy to lob a few copies of my communication skills manual to my health providers.  Sleep deprivation, anxiety, an overload of information, hormonal disruption and a sense of isolation make new mothers particularly sensitive to the language used by people they are supposed to be able to trust. Yet the disconnect between what professionals believe they are saying and what is heard is sometimes pretty staggering.

For example

Minutes after the birth, the midwife says You have flat nipples, she can’t latch on. I hear You’re already a failure, you won’t be able to feed your baby.

Another midwife says is that all you can express? I hear it’s not enough, it’ll never be enough.

The Maternal and Childhood Health Nurse says she has very slow weight gain. Have you thought of giving her formula? I hear You’re starving her. All those hours you spend feeding are a waste of time. Artificial milk is better for your baby than anything you could make.

The Maternal and Childhood Health Nurse says she’s a very shy baby! She doesn’t like being held. She gets so upset. I hear Your child is emotionally strange and needy, you have made her into a clingy, spoiled thing.

Absolutely everybody says Gosh, she’s so tiny/thin/little! I hear don’t you ever feed that child anything?

The doctor says Nine Months! Babies don’t need milk by her age. I hear You weirdo, why would you want to breastfeed such a big baby?

The doctor says New mothers are always so anxious about these things. I hear You are being neurotic and wasting my time.

But it’s not all bad news. I have finally found Dr. B – a doctor who speaks to me as if I am a real person with a real brain, and of me (and my mothering) as if, after almost ten months at it, I might have something worthwhile to offer my child.

Dr. B says It sometimes takes a long time to check these things out, but I like to be thorough. I hear your baby’s health is more important than my schedule.

Dr. B says What a lovely little girl! She’s so alert. I hear your daughter is intelligent and delightful so you must be doing something right.

Dr. B says Isn’t she tall for her age! I hear your baby is long and thin instead of reassuringly chubby, but she is growing so it’s okay.

Dr. B says It is very good for babies to play in the dirt – helps reduce their risk of allergies and boost the immune system. I hear your failure to mop the floors regularly is not only acceptable, it’s virtuous.

Dr. B says You are giving her the very best medicine she could have: breastmilk. I hear your hard work is worthwhile, your instincts are correct, your mothering is valuable. You are doing the right thing.

Exactly what every new mother wants to – needs to – hear.

It’s time we banished the disempowering language of body-conquering obstetrics and paternalistic peadiatrics into the pre-feminist vault where it belongs. We need realistic and reassuring language; praise and encouragement, not of the Hallmark Mother’s Day card variety but of the type that acknowledges the real and challenging work that mothers do, without belittling or cajoling or scaring the bejeezus out of us.