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April 23, 2018

Health: Breaking Bones



So I broke my right ankle (the fibula portion) in a couple places after I took a fall rock climbing in Yosemite.  I am totally fine, safe, and lucky.  After some more distance from that event I'd like to write more about it and what it means about climbing.  The short story is that despite a sucky outcome, it really was a positive experience in which I gained a lot of perspective about myself, the environment, and how we interact (as in, it's a relationship and there are moments to engage and there are moments to let things be).  Also my most prominent feeling is immense gratitude for having so many people in my life who are so supportive.  Thank you, I really love you and appreciate you!

Which is really what I was thinking about as I hopped my way through the well-oiled machine of the Kaiser system this morning.  That I'm really lucky to have the resources to navigate a sudden change in my life, and how much these things affect every level of daily life, which can then spiral.  And how different it is for our patients.

In medical school, I once attended a lecture on palliative care that started with: "Sudden illness and death are inconvenient."  We talked about how all the ways in which these things mess up our lives, the simple and basic daily things.  In medicine, we focus on how to treat the acute sickness and injury, but who is there to help cope not just with the physical illness but with the logistical nightmare of being a patient?

Sometimes we forget just how bad we are at this.  A big part of what sustains me at work are our clinic's shared goals to provide the best possible care to our patients who are at the highest risk for being sick and have the fewest resources to get better.  I always thought we're pretty aware of how our system fails them at every level, because we deal with the daily BS of not being able to streamline so much that seems basic: we can't get medical records, we can't get a medication covered by insurance, we can't find a specialist, and so on.  And we try to be cognizant of all the chaos and instability that makes it difficult for people to organize all the things it takes to be well.  We know that transport is expensive and physically difficult, that homes (if patients are housed at all) are not structured well for mobility, that food access and insecurity can matter more than diabetic medications.

But now being a patient myself (with plenty of resources) who is blown away by how much a small fracture can change your day to day, I'm even more struck by just how difficult it must be to be a patient at the clinic where I work.

Access: Last night, when I realized how swollen my ankle was getting and how little I could bear weight, I went online and was able to book an appointment with my primary provider the next morning.  This is almost never available at our clinic.  Patients can go to urgent care or to the emergency department, neither of which can give appointments, so you'll never know when you'll be seen.  And for a non-urgent injury like mine, this can mean hours of waiting.

Mobility: I saw my primary care doctor and she ordered an x-ray which I was able to get in the same building as her office.  At our clinic, we have to send patients to get x-rays at a totally different site.  It's not far, but if you've broken your ankle and it takes about ten minutes to walk a block, it feels freaking far.  I also got crutches immediately, with someone to show me exactly how to use them.  We don't have crutches at our clinic, and when we have to order any equipment like splints for patients, it can take them weeks and often months to get them.

Diagnosis: My x-ray was read immediately, and I was scheduled with a podiatrist (again in the same building) to discuss the results (which I knew was a bad sign for my ankle but at the time I was more preoccupied by how seamless this whole process was).  At our clinic, we wait for results of tests to be faxed over (yes, faxed), generally several days or weeks later, and often they're not faxed at all.  With thousands of patients, we might not remember that it was even ordered, and if they're not faxed to us, we might not remember to ever look up the results.  And certainly we won't be looking for them on the same day, unless a patient is savvy enough to pester us about it.

Specialty Care: I was pretty amazed that I got in to see the podiatrist just like that, on the same day. We have to refer patients out for most things, and even urgent referrals can take up to a week.  Normal referrals (which are sent out by mail to patients) take a couple weeks to process, which means it takes patients a couple weeks to just get a number to call, to then make an appointment to see a specialist, which can take who knows how long depending on the specialist.  We can expedite things, especially orthopedic issues like this one, but that requires extra effort and a different process (for which we don't get any extra time)--it's not standard of care.

And at our clinic, because public insurance won't pay for two visits in one day, patients can't see more than one provider.  Even though it makes sense, both for convenience and for coordinated care.  So even if a patient could see their primary care doctor, counselor, and gynecologist in one day, they're not allowed to.  (Though, I asked my primary care doctor today if I could also get my PAP done since I was already there, and she said only gynecology does that, and I was pretty proud that all of our primary care providers can do PAPs).

Procedures: Kaiser has in-house people to do everything, so once the podiatrist diagnosed me with the fracture he handed me off to someone else to do my splint.  The procedure was quick, efficient and mostly painless.

It was at that point, though, that I realized how drastically the procedures of my actual life were going to change.  How will I carry anything while using crutches?  How will I get to work?  How will I shower? How will I drive home with my right leg in a splint? (um, I did it against medical advice).

Luckily, I have a lot of resources. I'm easily able to take time off work, which is not the case for many of our patients who try to grab episodic work like manual labor as it comes, or whose employers are not sympathetic to people who need recurring time off because they find low-income workers expendable and replaceable.  I have friends and family who have cars; I have expendable income so it's not the end of the world to take a lyft or leave my car parked in a garage overnight.  I can't tell you how many times a patient declines to go to the emergency room for a legitimate medical concern because they don't want to leave their car parked at the clinic and pay that expense.  I have a loving community of people (thank you again!) who have the kindness and bandwidth to go out of their way for me.

I also have the entitlement of being able to advocate for myself.  While Kaiser was great at efficient medical care, they weren't the best at actually caring about what my life looks like outside of their utopia.  The podiatrist didn't give me much information at all other than I'd have to be in a cast, and I had to ask him for how long I wouldn't be able to do anything.  When he said 8 weeks (and neglected to ask me what it is that I'd want to be doing), I almost cried which was already embarrassing and since he tried not to notice it, I got even more embarrassed so I spent most of my energy sucking it up.  By the time I actually thought of questions to ask, he was gone and I was on my way to getting a splint.  But afterwards I realized I had a billion questions and I emailed him to clarify exactly what was going on and what I should expect.  Though I still didn't ask him about how I would shower (for that I went to google and the answer is cast covers).

I know from experience with many caring health providers that people rarely intend to be cold or unsympathetic, but that there's often a lot of other things to consider as a doctor and it can be hard to remember how to just be a person (ideally they aren't separate, but here we are).  For healthcare providers working in a system much less functional than Kaiser, there's even more to navigate, and we often forget to ask about how patients are going to actually live their day to day after they leave our clinic.  And they, unlike me, are often used to systems that don't cater to them.  They rarely ask: What should I expect?  And I too infrequently ask the questions that would help me advise them what to expect.

One of the first things my friend Diana (one of the best doctors I know) asked me was: "Are you going to be okay at home?"  Her thoughtfulness in realizing that a broken bone really means many little fissures in my life, and my confidence that yes I would be okay, reminded me again how much I have, how relatively easy it is for me to piece things back together after a break.

It's not this easy for everyone (please remind me I said this when I cry and complain over the next couple of months), and I think that's the main immediate takeaway for me in the day after breaking my ankle.  While I don't necessarily believe in pre-ordained reasons for things happening, I do believe pretty strongly in drawing purpose from things that happen.  I've been spending a lot of time doing the things I love lately, and at the same time becoming a little more stressed at work, which seemed a little off as the former usually helps with the latter. So maybe this is a timely way of forcing me to stop and re-evaluate what I'm doing at work so that we're better able to recognize where things are broken and how to help heal in the places that matter most.

1 comment :

  1. that podiatrist stinks! (stinks like feet!!)

    ReplyDelete

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