The benefits of my journal

My sister has a disease called Moya Moya which caused her to have two strokes. One was when she was 28 and the other was when she was 32. She has had bad headaches her whole life. It wasn't until I was in my early 30s that we talked about our headaches and realized how similar they were.

We both have auras, the "warning sign" that there is a headache coming. Unfortunately for both of us, the aura is worse than the majority of headaches. Usually, it starts with a blind spot and some mental scrambling, and I have had some difficulty speaking in the past. The speaking difficulty is the thing that took my sister to the ER and ultimately was the sign that she had indeed suffered a stroke.

In February, I started having headaches after 8 years virtually headache free. Yes, I have gained 30 pounds of happy weight since getting married to my husband, my blood pressure is borderline and my stress level is about 3 times what is was before my great professional support system changed. All of those things had a part in my headaches, but when I had a headache that included a numb left arm, I got worried. So, I went in for an MRI. Which showed some narrowing in the blood vessels in my head. Moya Moya? After lots of tests, I saw a Neurologist and he sent me to a Neurosurgeon to get advice about whether to have surgical intervention. Thankfully, I do not have Moya Moya.

My journal was a huge help in my week long marathon of visits at Mayo Clinic in Rochester, Minnesota. I saw the Neurologist and when she asked me when something happened, I could look back and see. When the headache Neurologist asked which medication helped, I could look at a calendar I created to keep track of headaches. I could look at my "headache watch" section of each day and tell the headache specialist what made a difference. I could also tell him what did not make a difference. I had a list of questions for the Neurosurgeon and was able to be sure all of them had been answered before I left the room.

Until health care changes so that there is less waiting around, a journal is also a great way to pass the time while you are waiting. My first journal was boring and not too fun to read again, but the more I do it, the more fun it is to go back and read.

I am almost to the end of my third journal of this type, it has taken me about two years to fill three. I use a journal that is about 7.5 by 10 inches a softcover Moleskine. I can't use a digital journal, it doesn't call to me the same way that a real, paper journal does. I paint in it, I glue things into it, and I feel like I live a little more every day because I keep track of important, and sometiemes not-so-important things. I am happy to report that this, my third, journal started with a health scare and ended with the good news that I do not have a progressive blood vessel disease. I can't wait to see what the next journal will help me to discover.

Health care is too expensive

I spend a lot of time with patients trying to get them healthy. I don't mean just prescribing medication, although I do that. I mean talking about other things they can do to stay or to get physically, mentally, and spiritually healthy.

One of my common recommendations is journaling. There are a ton of good books about journaling and the benefits you can get from the practice. I recommend The New Diary by Tristine Rainer. I love the tone of the book and I feel like it is inspiring without being preachy or weird in that touchy-feely, free-love sort of way that it is easy to fall into when talking about accessing your inner wisdom. 

Journaling is an inner wisdom thing; you try to find the answer you know but can't identify because you are too hard on yourself. Your best friend loses something and you say, "Don't worry, you did the best you could." But if you lose the same thing your inner voice calls you stupid, dumb, loser, insert your inner voice put-down here. It isn't pretty.

I've recently had some patients unhappy about the cost of their visits. Three out of 80 patients isn't a bad ratio, but it still bugs me. Unhappy patients, no matter what the reason, trigger my need to journal. It took a migraine headache and 4 journal pages to realize that my frustration came down to agreement. The cost is outrageous…and I have no control over it. 

Nationally, the average support needed in a healthcare clinic is 2.5 full time staff per provider (or up to 5.8 staff depending on the resource you use). At least one of those is dedicated to billing. Every insurance company wants something different. The same problem may have to be coded in 3 different ways for 3 different insurers to cover. This means that every patient that walks into the clinic has to pay for at least 3.5 staff positions. It's not fair, but that is the reality. It isn't the only reason for the cost, of course, but I wish more people understood it. 

I also wish people understood that I don't choose what they pay. All I do is see people, treat them the best way I know how, and chart what we did. There is some complicated way that the price is figured. I don't know how it works, and it is one reason I am not self employed. I would prefer if no one had to pay for health care. But that would mean that the system would not exist. It's a catch-22. Hospitals and clinics have to charge for services or they can't pay providers. If providers don't get paid, they can't eat. I like to eat. Eating allows me to see patients.

So, I apologize in advance. It is certainly not more expensive to see me than it is to see anyone else, but I apologize for the state of the entire system. It isn't perfect, but it's the one we are stuck with. The best I can offer you is advice; find a provider that you like and who helps you get and stay healthy and see them as rarely as possible because you are following the advice they give you.

Pets for longer life

I am nearly a 40-year-old woman and I have never had my own pet. I couldn't have just any pet because we already have a very large doberman named Madonna and most pets could be eaten by her. Madonna barks at cats and bullies other dogs; she is a little high strung. So I chose a pet that lives in a cage…and happens to  require temperature control, a light schedule and hours of bonding time.

My baby, Persephone, is a three month old hedgehog, and is a lot of work. She has an exercise wheel that she uses every night and does most of her pottying on it. Yes, it's as messy as it sounds. She huffs at you when she is scared and jumps with her quills standing up so that you get poked. Hedgehogs are nocturnal and are prey animals so they take a lot of time to get used to you because they think you are going to eat them, most likely.

My husband had a Doberman when we got married. She was his baby. He took her with to worksites, she slept at the foot of his bed and she ate about everything that he ate. He covered her up when the house was a little chilly and even had a doggy coat specially made for her. I thought she was spoiled rotten. I guess she was, but he was happier for having her in his life.

Now, I understand that a pet is not just a pet. We spend a lot of our time with our pets. Dogs will follow you around and make you feel like a hero every time you come home, even if you were only gone for 10 minutes. Persephone has stopped huffing at me and trying to poke me with her sharp quills. It makes me happy. Even taking care of her hedgie house, aka cage, makes me happy. Research shows that people with pets are happier and healthier. I get it.

Last night, I had a dream that Persephone died. I realized the attachment I have to her when I woke up crying and went to be sure she was okay. The death of a pet for some can be more traumatic than the death of a human family member. I have patients that cry over a pet's death and then apologize because "it was only a dog." I believe that pets are worth the mourning that we do when they die.

I am going to enjoy my baby and all the work that goes into caring for her. I am going to feed her mealworms, no matter how icky, so that she has a good, comfortable and long life. She is making my life longer and happier. Oh, and pokier, too!

Searching the internet for heartburn

Sarah came to see me the other day (not a real person). She was having some problems with reflux, or heartburn, and had some information from the internet with her. She told me that she tried some things she found on a medical web site, blocking her bed up so that she was sleeping on a slight incline, not eating or drinking for at least two hours before going to bed and cutting out spicy foods. She wanted to know from me if there was anything else that she could do before she tried medication to help with the heartburn. 

I asked her some questions about her symptoms to be sure she was not experiencing a heart attack. She was not having any alarming symptoms, so we talked about heartburn and reflux.

TREATMENT: We talked about cutting out alcohol and caffeine, which can make heartburn worse by loosening the muscle around the top of the stomach (the lower esophageal sphincter or LES). She drinks coffee in the morning and decided to cut back to half decaf. We discussed not overeating at any meal, especially dinner, to decrease mechanical pressure on her LES. She doesn't smoke, so that is not an issue, but it can be for some people, as it also loosens the LES. Sarah was surprised to learn that peppermint can also loosen the LES. So she said she would avoid the after dinner mint sometimes served at her favorite restaurant. She also had been drinking peppermint herbal tea before bed and decided she could change to some other kind.

THE POINT: This was a perfect internet research story. She looked things up on reliable sites and let me know what she already tried. She was open to more ideas and help. She had good questions and she had tried nothing dangerous. She looked the information up on a few medical sites with good reputations, to compare what she found. In short, she did her research, but didn't try to diagnose herself.

The internet is wide open. Just as I can say anything I want in this blog, people can say anything on the internet. There are no internet police, no editors, no peer review, no reins. When I was a child, we were taught that gossip was like blowing the seeds off a dandelion. You can't get the words back. The internet is a lot like gossip. Once something is on the internet, it can take on a life of its own. And it doesn't have to be right or true.  There is no filter.

There are some really good medical sites that are peer reviewed. This means that one person can't say whatever they want. There is consensus behind the information and usually backed by research. This is the filter. Two good places to start to get more information or do research on the internet are Medical Net Top 20 and The Medical Library Association. They both have lists of sites that would be good places to start for reliable information. 

Eat right and exercise?

What is your health goal for this year? We all want to "eat right and exercise" but what does that even mean? Chances are, last year you vowed to eat right and exercise but nothing changed. Or maybe it did…for a week. I am guilty of this, too. I gained about 30 pounds two years ago and haven't taken it off. And I, like you, know exactly what I am doing wrong. 

Here are my whys: In order to be good at my job, or any job, physical health is imperative. I'll be more efficient and be better at sleuthing if I am taking care of my physical health.  Staying healthy for me is imperative. My family history includes heart attacks before age 50 and strokes.  I have been in good shape. I remember how good I felt. The energy level, the clarity of thinking, the decreased need to sleep my life away "catching up" on the weekends. (Which doesn't work. It just makes it harder to get up on time for work.)

Eat right. There are about a zillion different ideas about how to eat out there. Low carb/high fat, high carb/low fat, vegetarian, vegan, fast food…oh wait the last one isn't actually a diet. But wait, if you are regularly consuming fast food, it is your diet (food and drink regularly provided or consumed- Merriam Webster). Do you really think that fast food diet is healthy? Really? So, start your healthy goal by eating less fast food. You know where to start making changes. Start there. And you can go here for help http://www.webmd.com/diet/myths-vs-facts-10/lose-weight-safely.

Fad and extreme eating is all the rage, the names and foods change a little, but the concepts don't. If the diet you are contemplating has you eating fewer than 1200 calories a day, you will not maintain your muscle mass and be unable to add exercise. And you will be going the wrong direction. A loss of muscle mass means that your body is burning fewer calories and it's just not sexy to be all baggy and floppy. There are a lot of current celebrities who are very thin but what my friend, Dr. Willey, calls skinny-fat, higher in body fat and with very low muscle mass. It is not healthy to be so weak that you are unable to pick up your kids or run a mile or ride a bike. The idea of this whole healthy thing is to be, well, healthy. That means you want your body to do anything you want. Run, walk, swim, move furniture, whatever you desire. 

Exercise. How? You already know how to exercise. Move more. Find something that you love to do and then do it. Every day. The only thing I will add is to be an underachiever when you begin. Most of us, especially in January with New Year's goals, will start out by working much harder than we should. Why do we do this? We don't trust that we will follow through with our goals. So, make small goals every day. Start by getting started, but leave something in the tank so that you don't get so sore you can't move. That will derail you. And measure. Keep track of what you are doing, the amount of time you spend, the weight amount if you are lifting weights, the difficulty level. The gains you make will be your inspiration on the day you don't want to do it. 

What do you say we get started? There are so many reasons to get healthier this year. Find your why. What makes your toes tingle when you think about it? What will really get you started toward creating healthy habits? Today I ran one mile. Not much, but it's a start.

Time is slippery

Time is a great two faced monster. In between patients, when I am charting and composing letters, time sits on my shoulder and breathes in my ear…hurry, hurry, hurry. During phone calls, he is less insistent. As soon as I walk into an exam room where a patient is waiting, time leaps from my shoulder and waits to pounce as soon as I come out. 

Asking questions and getting to the bottom of the problem are my favorite things. When did it start? How long does it last? What does it feel like? Have you ever had it before? What do you think it is? I am allowed to be nosy. In school we learn that the diagnosis is 90% history. That means you tell me what is wrong before I ever lay hands on you. If you ever notice a frustrated health care provider and you happen to answer in one syllable, this is why. 

While sleuthing for answers is usually fun, there is one phrase that will kill it. "You're the doctor, you tell me." The human body is not a stereo. You cannot open it up and look into the back, solder something back together and be done. There is no jiggling it to see what is broken. When I started school I thought it would be easy. I thought that a patient would come in and tell you the symptoms they were having, you would reach back into your memory and say ahh, those symptoms equal this problem. Here's your prescription. Yeah. Not. I need you to tell me all of the pertinent details to figure out whether you have a horse or a zebra (I will explain the zebra thing later).

For lots of reasons, patients are sometimes trained not to give all the pertinent details. When you have a provider that has been seeing patients for 20 years, they often figure out what is happening in the first few minutes. And they are usually right. I have found that being a relative newbie is helpful because I have to ask more questions. Sometimes, one answer changes everything. You may get cough syrup…or you may go to the Emergency Room. I will spend more time getting there than my learned and experienced counterpart.

So, time stops in the room with a person who is hurting. It starts again when I step out into the hall. Unfortunately, I have sometimes spent too much time with one patient at someone else's expense. I feel bad for that. But I feel very good when I can look back at the end of the day and know that I did all I could for each patient. I hope that the people who come to see me feel supported and are willing to wait around just a little bit so that everyone gets what they need. It isn't the most efficient way, but it's the most caring way I know to do the job. One day, I will kill the two faced monster. Probably right before I die.

What I do

Hi and welcome to Health Care Insights!

Why would you read my blog? I am going to attempt to give you some insights from behind the white coat. 

I am Rebecca and I am a Family Practice Nurse Practitioner, also known as FNP. I work in a clinic in a small town in Montana and absolutely love my job.  I take care of patients on a daily basis and teaching them anything makes me love my job. I love to teach.

What is a Nurse Practitioner? It isn't an easy question to answer. The short answer is I am the person you see when you go to the "doctor's office" and don't see a doctor. Another short answer is that I am like a PA, if you know what a PA is.

The truth is, I can't tell you that I am like a doctor because I work with doctors every day. They have a lot more education and training than I do and it would be presumptuous of me to say. I do similar things to a family practice doctor. I see patients and examine them, order tests and prescribe medications. It fits well with my personality because I do well with new challenges daily. I can tell you I had no idea how challenging it would be when I started!

The most challenging thing about being a FNP is time. I worry about giving each patient enough time so that they get what they need, and I worry about the next patient who may have to wait if I take too long. I don't wear a watch, which helps me to be attentive to the patient I am with. I don't have to leave the watch at home, but I like the symbolism.

Before I was a nurse,  I had a surgeon who was 4 hours late for my family member's surgery. He told us when he came in that he had been with a woman with newly diagnosed breast cancer and she needed him. That impressed me. When I became the one "in charge" I wanted to be sure to rise to that level of care and compassion.

My pet peeve of the day is when a doctor of any kind doesn't know what a FNP is. I had a physician call me once when I was on call for the clinic (which includes me, two family practice physicians and an internal medicine physician). He told me if I couldn't find someone to make a decision about a patient, I should send them to the Emergency Room. The gentleman was very condescending and rude. He was not aware of my position, training or responsibility and treated me like a staff nurse. Unfortunately, the staff nurse is the most picked on, disdained,  and undervalued position in medicine. The good ones are good because they are fearless. They stand up for the patient no matter who challenges them. I decided it wasn't worth fighting with the physician since I sent the patient to the ER anyway. Rant over.