Category Archives: Professional boundaries

Blog: Rural Mississippi—Aftermath of Hurricane Katrina

–Shailendra Prasad

August 2005. I planned on flying back to New Orleans after a conference in Arizona. My wife and son had accompanied me. We watched Katrina grow like a weird reality show—a petulant child gaining weight, becoming unruly. There was talk about this being bigger than Ivan from the year before, even bigger than Camille from 1969. “No,” my friends and patients in Mississippi told me, “nothing gets bigger than Camille.”

Our flights home were canceled. Then we learned our neighborhood was under mandatory evacuation. Evacuation was not foreign to us. We’d participated in four drills during our seven years in Mississippi. “Hurricane parties,” we called them. We’d lock the shutters on the house, secure the garage door, and remove the yard implements that could become missiles in the sixty plus mile-per-hour winds. Then along with our two satchels filled with a change of clothes, our son’s favorite toys, and copies of our important documents we would drive to a safe home, a friend whose home was not in the path of the storm. We’d spend the night playing cards, talking, and waiting out the squall. Usually we could go home the following morning.

We hoped this, too, would pass and called a friend who had a spare key to our house.

“Sounds like a bad one,” our friend said.

“Can you get our hurricane satchels? There are two of them, in the closet in the master bedroom.”

“Sure. I’ll lock up the house too. Anything else?”

“Yeah, put the birdfeeders in the garage. The birdbath too.”

“Of course. Be safe. I’ll be in touch.”

That night in Phoenix I watched the television. Reporters talked about the rain and wind in surrounding areas. Counties in both Mississippi and Louisiana were evacuated. I called every number in my cell phone. No answer at the hospital, the clinic. My practice partner did not respond at his home phone or cell. I could not reach our neighbors or local friends.

Our county, Pearl River, and our town, Picayune, were orange on the weather map. The Internet news pages said nothing more. I could not eat dinner. I continued to make calls. I phoned my dozen sickest patients whose numbers I kept just in case they needed me. No one answered. I worried about my three-year old patient waiting for a renal transplant at Tulane. He’d just gotten a match.

What would happen now? No answer. And there was complicated Mr. Shirley who I just referred to the neurologic unit in Birmingham, Alabama. Would he get there for his appointment? When was that appointment? No answer. Then there was my dialysis patient. Where would she go? No answer. Feeling restless and helpless I walked down to the business center and opened this blog:

Pearl River County Katrina Survivors

This is my attempt to help in the aftermath of Katrina. I work in the Picayune area and have very dear friends in the area. The only precondition to this blog is this—respect your fellow bloggers.

Please blog away to add on to the information on Picayune/Pearl River County,Mississippi.

posted by sprasad @ 8/30/2005 07:54:00PM

By midnight there were thirty posts. I am looking for . . . I am trying to reach. . . does anyone have any information on . . .

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Prasad felt an obligation to his patients during Hurricane Katrina. Medicine is rarely something you can walk away from when you leave the hospital or office. Often you carry patients with you – think about them, worry about them, pray for them. In a small town you often see  patients as you run errands at the hardware or grocery stores. This raises the issue about how one sets boundaries. How one cares for his/herself.

Talk with your preceptors and other staff in you clinical setting and see how they manage these challenges. 

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Professionalism

–David Loxterkamp

 The family doctor is a hybrid in the field of medicine. We perform the generalist’s role with specialists’ ambitions. We are amateurs (from the Latin amator) who love our labor and shoot more from the hip than from the sights of expert opinion. We still consider medicine a vocation, or calling, and thus remain open to duty that lies beyond the roles for which we’re prepared. And, we remember that professionals are those who profess something publicly about what they believe.

I have listened to the professions of Trappist monks at New Melleray, Gethsemani, and New Clairvaux abbeys. Not only do they commit themselves to the religious life (in the vows of poverty, chastity, and obedience) but pledge to live in one place (the vow of stability) in order that grace, working through community, may move them (by a conversion of manners) closer to God.

Family doctors, too, understand that our high incomes distort our perceptions of the poor; money tests our personal values and stands between patients and their access to medical care. Chastity reminds us to be respectful of the intimacies we guard and faithful to those who are marginalized by the loss of insurance or physical well-being. We remain obedient to a higher authority—the precepts of science and a moral conduct befitting our profession. We realize that patient care is not portable and that the doctor who lives among his mistakes and prejudices becomes a healthier person less prone to severity in the judgment of patients or peers. Lastly, family doctors are inevitably changed by the patients they serve. The merely responsible physician, tempered by mercy and groomed by grace, adds to the stock of moral credibility that has sustained our profession over the millennia.

 What I am trying to describe is a doctor who is more than the sum of his or her parts, more than a tally of screening tests and minor procedures and patient encounters scored over the course of a career. We might more easily see that a rabbi or minister is not only master of ceremonies but a person praised as a man of God. We know that a teacher is more than a conveyor of facts and proctor of exams but someone dedicated to the channeling of curiosity in the pursuit of truth. So, too, family doctors, who through the blur of ICD-9 and CPT codes will finally rest in those relationships that define and sustain their work.

(Excerpted from A Vow of Connectedness: Views from the Road to Beaver’s Farm, The Country Doctor Revisited (KSU, 2010) and Family Medicine (2001) used with the permission of the author)

 Dr. Loxterkamp wrestles with big issues. He does not use the word, but the physician is a healer– he/she takes a vow much like a monk or holy man. Medicine is more than science, but the art. There is an understanding between the patient and the physician that the physician will practice in the best interest of the patient, not simply for his or her own reward. Dr. Loxterkamp believes that physicians are called to something greater than simply an occupation.  What are your thoughts on this? In today’s production and profit oriented health care systems is this even possible?

 Dr. Loxterkamp admits that in family medicine we often shoot from the hip.  That may be heresy in the world of evidence based medicine. We have reflected on this in other posts–balancing the art and science, balancing the evidence and what makes sense for the patient. How do you see the health professionals you work with blend what the evidence tells us and caring for patients where there is no evidence to guide us? Are we shooting from the hip? Is there more to it than this or are we fooling ourselves?

 Dr. Loxterkamp suggests that in small communities we “live among our mistakes.”  In small communities we cannot hide. What does it mean to live among your mistakes?  How does one reconcile that a medical mistake may harm someone?  Perhaps after all we are our own worst critics? Sometimes community members can be quite forgiving of the doctor’s foibles and even look past what might be poor care because they value their relationships with the physician.  How does a physician stay honest to the profession and his oath to care for his/her community despite the current incentives in health care, depite the fact that we are human and will make mistakes?

Read Dr. Loxterkamp’s entire essay in Family Medicine

A Vow of Connectedness–part 1

–David Loxterkamp

 I have known Beaver for a dozen years. He is a member of my parish, a patient in our practice, the host of our son’s summer camp excursions, and a grandfather figure for my daughter, who helps with the summer milking. His daughter-in-law once worked in our medical office. He and Dr. Hughes forged their friendship years ago in Tim’s two-man racing shell. One of Beaver’s sons married the next door neighbor (she had been among my children’s favorite babysitters).

 One can be seduced into politics by the notion that popularity, moral righteousness, and a good grasp of the playing field are a guarantee for success. So, soon after establishing myself in medical practice, I joined the parish council, spoke up at hospital staff meetings, and ran for the school board. Mine was a voice for family practice values. I helped children become more involved in church worship, opposed screening programs that reduced health care to a commodity, and supported neighborhood schools that fostered strong relationships between teachers and the wider community. In these and other debates, I was frequently on the losing side. You might have thought that medicine—where the patient’s struggle against mortality is conceded from the start—would have prepared me for poor outcomes. Even in victory, the politician is left with a compromised and transitory gain. He must cherish the political process more than the final vote—likewise, the doctor’s reward, which lies in a love of his or her patients and the provision of good care rather than in any false hope of transforming the misery that parades past his or her door.

 Change

Is the family doctor an agent of social or political change? Perhaps some of us will shape and leverage the national debate. More will run for elected office in our home state or municipality. The rest will do their part by maintaining the connections that are severed in patients’ lives during the course of their disease, despair, addiction, or aging. For them, the doctor holds the flicker of hope, the reassuring hand, a mirror of their self-worth, and sense of dignity. Through our own lives, we model the possibility of change.

 I have saved only a few of my patients. I have seen alcoholics give up the bottle, wives flee the battering hand, the morbidly obese shed an elephant riding on their backs. But most of what the doctor accomplishes is infinitesimally small, barely a quiver, broad and trickling like the St. John’s River for those who are succored in the watershed of our care. We are stewards of a human ecology. Our practices are strengthened by diversity, interdependence, and the desire for our mutual long-term survival. We are caretakers of what Robert Putnam calls “social capital.” The wife of a patient of mine, home dying of lung cancer, recently said to me, “Dr. Loxterkamp, I just feel better knowing that you drive by my house every morning.”

 (Excerpted from A Vow of Connectedness: Views from the Road to Beaver’s Farm, The Country Doctor Revisited (KSU, 2010) and Family Medicine (2001) used with the permission of the author)

Read the entire selection

 Dr. Loxterkamp reflects on how intertwined our lives are with those of our patients in rural communities—babysitters, role-models, etc. In other selections, we have talked about how our patients are often our friends and the importance of figuring out how to create boundaries. Post January 2nd. Here Dr. Loxterkamp explores the big fish in a little pond phenomenon of the local doctor.  For some physicians this may be a “fish bowl” experience where everyone knows his or her business in a way that is unpleasant. For other physicians this may be a one of the benefits of a small community where he or she can be a leader and a role model in the community, a mover and shaker, even politically involved. Others look up to him/her for his/her opinions, ask for money, support, etc. Some personalities may be better suited to the ‘big fish in a small pond’ experience. Think about the health professionals in the community where you are rotating—where do they fall on this continuum??

 This being elevated to a pedestal, the accumulation of power and prestige can go to one’s head.  The national media is filled with the stories of celebrities and politicians who “have fallen from grace, ” who think they can live by different rules. Dr. Loxterkamp does not use the word humility, but he hints at it when he warns about: “false hope of transforming the misery that parades past his or her door” and “I have saved only a few of my patients.”

We are reminded that although others may look up to us, we still live by the same rules as anyone else.  Like anyone else in the community we are human, we each have our strengths and weaknesses, and our challenges– we each must live by the same rules.

 Finally, Dr. Loxterkamp reminds us that as healers we have the opportunity and privilege of giving others support and comfort during the journey of life. This is a privilege. During the years of practice in a community one sees births, health, illnesses and deaths and all the ups and downs in between. He reminds us to appreciate the gift of the intimate view into the human struggle of our patients.

 Reflect on the role of the physicians or health professionals (nurse, pharmacist, health care administrator, chiropractor) in your community. What have you noticed about the respect they do or do not garner from others? How do they respond to the privilege of walking with others? Please do not share identifying characteristics.

End of life decisions–becoming your grandfather’s physician in rural Tennessee

–David McRay
Dr. McRay tells the story of helping his grandfather decide to end dialysis and agreed to be his physician so he could die at home. ..

As his creatinine level rose, his hematocrit fell, he had no choice. With the itching worse and the fatigue incapacitating, if he wanted to feel better—in fact, if he wanted to continue to live—he needed to begin dialysis. He did not understand what was being offered, how it would work or how it would make him feel. The therapy was never described as a form of life support
with all the customary conversations about indications, alternatives, ethics, and options for withdrawal. It was simply the next step in the management of his illness; a step he felt forced to accept but never really did.

The nearest dialysis center was in a town forty-five minutes north. Three days a week, my grandparents would leave home early in the morning and make the trip to greet the staff and submit to “misery,” the word he used to describe the way dialysis made him feel. Miserable though he was, he made the best of the situation, as he had always done with every hardship he encountered in his life and for two and a half years, he drove himself to dialysis most of the time.

A stroke changed everything. He awoke that morning with some troubling weakness and numbness in his right arm and leg. An ambulance trip and brief evaluation in the local hospital emergency room were followed by a transfer to the major medical center in Nashville where my grandfather remained hospitalized for two weeks. He was discharged to a rehabilitation hospital and then an extended care facility. He never suffered from a severe loss of function, but he became dependent, unable to attend to his most basic needs. His dignity was under attack; his spirit broken.

When his wife of sixty-one years passed away in her sleep, he asked, “What will happen if I don’t go back to dialysis?”

“I don’t know” was the only answer I could provide. I had never encountered this circumstance before. I knew he could delay his treatment a day, maybe two. A few days later, I spoke with a nephrologist in my community. She seemed very uncomfortable with the conversation and described the difficult deaths of two patients who chose to stop dialysis during her fellowship. Beyond that she offered little.

Granddad approached this decision in his usual careful and thoughtful manner. We continued our conversation and I tried to answer his many questions. We referenced the Christian Scriptures, talked about his relationship with God, and spoke of the confidence with which he felt he could approach the end of his life. We discussed other situations in which patients make decisions to withdraw life-sustaining medical care such as mechanical ventilation and tube feedings. He concluded that for him discontinuing renal dialysis was similar to discontinuing mechanical ventilation in the face of an irreversible, terminal illness. His kidneys had failed and would not recover. His life was without joy and now devoid of the experiences that had given it rich meaning for almost eight decades. Existence was limited to restless sleep on the bed or the sofa with painful, exhausting, and embarrassing trips to the bathroom.

Dr. McRay’s grandfather was enrolled in hospice and Dr. McRay agreed to become his grandfather’s physician so he could die at home. ..

The morphine and the hypoxia-induced sleep kept him unaware of the fluid that was filling his lungs. “I’m ready. Let’s go home,” were his final words. He slept and did not arouse again. His son held one hand and his daughter the other. I moved across the room and sat in a chair, watching with quiet reverence. This location provided my parents, aunt, and uncle enough space to be at his side. Perhaps the move was symbolic as well. My grandfather was dying on the couch, but he was also my patient. I needed to maintain some space, to hold on to the equinimitas I had found. Until my task was completed, I wanted and needed to protect my objectivity.

The end came quietly. Some of those present had never witnessed a death before. Startled, they looked to me for an interpretation, a diagnosis, a verdict. My solemn nod unlocked the door to their grief. Together we—his family and friends, his church and community, and me as his grandson and physician— allowed my grandfather to go home and stay home. With grace and courage, he overcame the obstacles presented by the rural location where he lived. With
hesitation and gratitude and with some sense of urgency and necessity, I overcame my uncertainty about the dual roles I was asked to play. I was honored and humbled by the privilege of helping my grandfather write the final chapter of his story. I believe he wrote it well.

Dr. McRay explores a number of important issues: ending life sustaining treatment such as dialysis, managing the dual roles—grandson and physician, the value of religion in exploring the big questions in life. In today’s world technology creates benefits and burdens. We can extend life, but those days and months are sometime more quantity than quality. Dr. McRay helped his grandfather decide to quit dialysis. Have you witnessed or been part of such discussions and decisions with patients? What did you learn? What will you take away from this essay as you help patients explore how they want to die and make decisions about resuscitation, intubation and advanced directives? How is religion and spirituality helpful to patients who have a faith?
Dr. McRay negotiates his dual role more carefully; this is explored more fully in part of this essay that is not included in the blog. What are important considerations for managing the dual roles?

Published in The Country Doctor Revisited (Kent State University Press, 2010) used with the permission of the author

Teen Pregnancy

“We Were Hoping”

–Patricia J. Harman

At 4:00 p.m. Dee Telemann is fifteen minutes late for her 3:45 appointment. It gives me a chance to return a few phone calls. It’s a familiar last name, Telemann. She’s probably the daughter of my patient, Sara, who lives on a farm out on Snake Run.

At 4:45, an hour overdue, the patient arrives with a boyfriend. Dee sits on the edge of the exam table, a petite blond with the smooth tan skin and high cheekbones of a lot of Appalachian women. She’s dressed in jeans and a low-cut white blouse. Her young man slouches in the gray guest chair in a T-shirt with some kind of motorcycle logo on it. He wears tight, worn jeans, a creased baseball cap, and run-down cowboy boots.

“Hi, Dee, I’m Patsy Harman, nurse-midwife and GYN practitioner.” I reach out my hand and note the girl’s firm grip.

“This is my boyfriend, Jerry,” Dee says proudly. “My fiance.”

Jerry nods and meets my eyes. He’s a small guy, but muscular, about five feet nine with light brown hair curling over his shoulders.

I glance at the birth date on the patient’s chart. She’s sixteen. He could be eighteen. Because she was late, I’d been prepared to start off the encounter with a lecture about the importance of coming to appointments on time, but curiously I skip it. “So Dee, what brings you here today? Are you having difficulties?”

“Oh, no real problems. . . . We’re just pregnant. We did three home tests.” Her face glows and she looks at Jerry for confirmation. He grins but then quickly pulls a shade over his joy.

“So, is this a good thing that you’re pregnant? A happy thing?” From the look that has just passed between the two lovers, it’s obvious.

“Oh, yeah, we were hoping it would happen. The only problem is, we don’t have any money or a medical card. I was hoping you would take care of me until I can get one. I wish you could deliver our baby too, but the receptionist said you don’t anymore.”

“Do your parents have health insurance?”

“I don’t know, but if they do, it wouldn’t cover me. I quit school.”

I want to ask why she dropped out. She seems smart enough, but I stick to the subject. There will be time for that later. “Have you applied for medical assistance?”

“Not yet. We need my mom’s signature or a health care provider to verify that I’m pregnant. I was thinking that could be you. . . . We need a due date too, on the form.” She stops. They all stare at me.

“Does your Mom know you’re pregnant?”

“Not yet. We wanted to wait until Jerry gets his first paycheck from Taco Bell so she’ll see we can be responsible. She doesn’t even know I came to see you.”

Sara Telemann, married, thirty-four, a rural postal carrier, has eight children. I delivered the last one. Will she be happy when she finds out the news? Does she expect her daughter to get pregnant early and often? Or will she be angry seeing Dee repeat the old pattern? I glance over the new OB intake form. The girl is low risk. Like most teenagers, she hasn’t been around long enough to have many medical problems. After a quick physical and a review of the OB packet, I take them all down the hall to the ultrasound room. Standing in the dark, I point out the tiny fetus on the monitor. It’s just eight weeks, but it has arms and legs and there’s a flicker of a fetal heartbeat. Dee has tears in her eyes, and Jerry reaches over to touch her bare foot. I give them a picture of the baby.

In the end, I sign the papers for the medical card and tell the young woman to call the welfare office first thing in the morning. “And I want you to tell your mom about the pregnancy before your next appointment. Legally I can take care of you as an ‘emancipated minor,’ but I would prefer it to be out in the open.” I don’t say, “Because if your mom comes to see me, you may meet one day in the waiting room.”

Dee and Jerry will be good parents. Maybe they’ll be parents of eight like Sara. Their children will be responsible, well behaved, and loving like Sara’s and get pregnant at sixteen or seventeen and have more babies. They’ll work at Taco Bell or Wal-Mart or Select Tech, the telemarketing place downtown. Maybe one or two will stay on the farm or go to community college for nursing or computers.

Standing at the checkout desk, I watch the young couple leave with arms wrapped around each other. They have everything against them—youth, poverty, and lack of education—but they love each other and seem so solid. I think of a mountain covered with trees.

Midwife Harman explores issues about caring for patients who have different values and goals than we do. How do you remain nonjudgmental and respect your patient’s values and goals, which may be different from our own? Have you seen examples where this is done well or poorly? Share those without divulging the identities of those involved. Midwife Harman refers to an emancipated minor. Most states allow providers to provide care to teens without parental permission. What is the value of this law? Have you seen your providers use it? What are the challenges in rural areas? Midwife Harman shares one.

LIFEprayerDEATH

–Kathleen Farah

“I prayed for you”

she said.

“I prayed every day you would have a healthy baby.”

I did.

She sat across the aisle from me at church you know,

Exchanged greetings of peace and watched my pregnant belly grow.

We prayed.

Tall in my white coat I stood before her in shivering snowflake gown.

My eyes and hands observed the tumor her right arm birthed had grown.

I sighed.

Too few weeks later I kneel beside her in her home hospice bed.

“I pray for you”

I silently said.

Words and tears are blocked by “professional boundaries” in my head.

I silently cried.

“I pray you have a peaceful death.”

She did.

Dr. Farah explores professional boundaries, prayer and expressing emotions with patients. As we have explored in other posts (Onime) dual relationships are common in rural areas. Our patients are our friends, and expect to be. We may see them at church and at the grocery store. Close relationships increase compassion, but may also bias us in our care for patients. Being close to a patient may make us more compassionate in giving bad news, but may make it harder to help a patient make decisions about their care because we have our own opinions and hopes as their friend.   What have you seen on your rural rotations?

Dr. Farah also explores expressing emotions with patients. Crying with and for a patient is not a bad thing as long as we can step back and be in our doctor role when we need to be. The ability to move from one role to another is often called compartmentalizing. This allows us to switch between roles. For example, in a crisis, I need to put my feelings aside so I can think clearly and make decisions about what to do. Feeling sadness or happiness for and with patients is also quite human and shows that we care. Grieving the loss of a patient we were close to is normal and healthy.  As a physician we are privileged to walk through the best and worst of times with patients. It is important to learn how to distance ourselves from some of the intense emotions, otherwise the roller-coaster ride of highs and lows is exhausting and draining. However, not taking the time to feel the feelings at all can lead to cynicism and burnout.

Dual relationships

–Godfrey Onime

The yellow-, red-, and green-striped gift bag containing the present lay on my office desk among the stacks of charts and assorted papers. Curious as to the sender, I looked at the card that came with it. “Oh no, not again.” It was from my patient Ms. Emalee, next on my schedule. Among her myriad medical problems—diabetes, hypertension, obstructive sleep apnea—was intractable knees and back pain for which she used narcotics chronically. On her current visit I’d planed to perform a random drug test, to ensure she was actually taking the medications and that she did not use illicit drugs. But now the gift, although this was far from her first—she often brought fruits, baked goods and other presents for everyone in my clinic. After she learned I got married and hinted she was looking for “something special” for me, I’d entreated her not to worry. She had looked at me as if I were from a different planet and then declared I was “like family now,” adding “you better believe you getting something from me, don’t matter you snucked off ‘n’ got married without telling no one.” Now I wondered: What if her test results indicated a problem? Would her act of kindness make it difficult for me to do my job, such as refusing to prescribe further narcotics or even discharging her from my practice?

 The question of boundaries with their patients is one issue that small-town doctors face. Often for lack of convenient alternatives, country doctors not only have to take their friends on as patients, but their patients quickly establish themselves as friends. It seems to challenge the reader to consider that in small towns, where privacy is shunned and familiarity with neighbors prized, maybe physicians’ closeness with their patients is exactly what they need to render care with true understanding and deep compassion.  

 When I entered Ms. Emalee’s room, she looked up at me expectantly and asked if I liked her present. I told her I had not opened it. Sensing her disappointment, I quickly added that I was waiting to get home, before opening it with my wife. The explanation seemed to satisfy her. “Smart man,” she said, “I’m sure she’d love it.” Ms. Emalee’s knees and back still hurt, but her pain medications were helping. No, she did not have significant side effects from the medications, such as constipation or drowsiness. I also asked if she ever sold her pain pills, but that seemed to annoy her. “You keep asking me that foolish question every time I comes here and I keeps telling you no, I does not sells my medicines. Don’t you even trust me?”

I apologized, but reminded her it was the law and my job to ask. At the conclusion of the visit, I told her I’d like a sample of her urine for a random drug test. “Whatever you say, doc,” was her sarcastic reply. Then she informed me they were having a birthday party for her mother—who was also my patient (as were her two sons, a daughter, a sister, and brother-in-law). Her mother was turning eighty. Her family would be greatly honored if my wife and I could come. Not sure how to respond, I promised to get back with her.

(Excerpted from Who We Are—Synopsis, The Country Doctor Revisited)

Boundaries between physicians and patients are usually different in rural areas than in larger metropolitan areas. Students are often caught in a double bind when they learn in medical school that physicians cannot be friends with their patients, but see in rural areas they usually are. As Dr. Onime states, “Patients often quickly establish themselves as friends… and that closeness may be what is needed to render care with true understanding and deep compassion.”  What do you see as the benefit and downside of “dual-relationships” –friend and doctor to the same person?  How do the professionals on your rural rotation negotiate this? Physicians often feel like they live in a fish bowl, especially in small towns where everyone knows everybody’s business. How do your preceptors draw the boundaries? Some professionals relish being the heart of the town and others prefer much more privacy. Imagine yourself as a small town practitioner, what would you do?