healthcare. right or privilege?

I have a colleague who loves to ask eager medical students whether they believe health care is a right or a privilege.  It’s a question that many of them have not really thought about.  I have enjoyed listening to their thoughtful answers as they work through the complexities that go along with a question like this one.  Quite a few of them, after giving their best answer, ask my physician friend if they got the “right answer.”  It makes me smile.

It doesn’t take a medical degree for you to figure out that the healthcare system is broken. It is a problem for which there is no easy fix. We know that the cost of healthcare is going up.  We know that the health of Americans is not really improving. Medical knowledge and technology is expanding at a rate more rapid than ever before.  How do we keep up?  Who gets access to what?  On top of all this we are facing a physician shortage in the near future.

Is healthcare a right?  Does a patient who hasn’t taken care of themselves when they were younger have the right to access to expensive interventions to restore health later in life?   Or is healthcare a privilege…something that you get to access because you have put yourself in a position to get affordable care.  As a society we have already chosen to ensure access to almost all our children and pregnant women…but what about everyone else?  For a nation that is in the top 3 countries in spending on healthcare we cover a significantly lower number of people with that huge dollar amount.

One of the best answers I heard from one young medical student was “healthcare is a right that we should treat like a privilege.”  It’s one of the truest statements I have heard.  Your health really is a privilege.  Ideally we would cultivate a nation where our young people take care of themselves, engage in a healthy lifestyle and we promote preventative health and disease prevention.  But what else can be done?  I think we can each do our part.  For me, it means talking to moms about promoting healthy behaviors not only for themselves but in their children.  It means that I advocate for my patients and work to improve the system I work in.  It means I support the after school program at my church so that young children around me can have access to healthy food and support for their education.  It means supporting my community in efforts to improve public health.

Everyone should have access to good health.  Does that mean healthcare is a right?  Yes.  Sure, how we improve the health of our society is a complex problem.  But I believe that each of us can find a way to improve our own health and the health of those around us.  Let’s start treating our health like what it is…a privilege.

kms

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evidence based medicine and faith based theology.

“May we be prisoners of hope in an evidence based world.” – Pastor Jon Middendorf

Last Sunday I got to hear an excellent sermon out of Genesis 15. God comes to the very old, very infertile Abram and Sarai and promises them something they have no shred of proof for…a child.  And he offers no real evidence or proof that He can do it. It’s a beautiful passage where God makes a covenant with Abram by walking him through a suzerain treaty: where God essentially says I will risk my life for you.  There is no evidence. Only faith.

Pastor Jason operates most of his daily life in this faith based world. He prays for the sick, welcomes the newborn, brings communion to the homebound.  He doesn’t need statistics or textbooks to tell him how to do this business, he uses faith. Me, I operate, mostly, in an evidence based world.  You see, health care providers rely on evidence to try and make the best decision possible for our patients.  Some clinical scenarios have a tremendous amount of medical evidence that back them. For example, we used evidence to determine when to screen for cervical cancer, to know whether or not to give antibiotics prior to performing a surgery or what kind of treatment is best for certain types of cancer.  Medical evidence can change; sometimes what we thought was true is shown not to be through rigorous scientific studies.  Sometimes two scientific studies will contradict each other.  Sometimes there is very little evidence to guide certain clinical situations.  As physicians we try to use the best available evidence and our best clinical judgement to guide care.

But there are places in life where there is no evidence.  That’s where faith steps in.  Sometimes people don’t need evidence…they need hope.  You can tell a mother who just experience a miscarriage what the evidence says about her chances of future successful pregnancy but she doesn’t want numbers…she wants hope.  When you diagnose someone with cancer you can give them evidence based survival rates but what they want is hope.  Faith and hope is when you reach across the exam room and give a hug, a handshake or a tissue.

Where hope and evidence intersect is where medicine really happens. To use the best evidence available to take the care of your patient and then to give them hope that you will do your best. To have faith that what you do each day adds value to your community and the hope that your best efforts will bring health to your patients. To commit to be a prisoner of hope that believes they can make a difference in the world.

family resemblance.

I often catch myself doing something that one of my family members would do.  For example, when I heat up my coffee in the microwave and forget about it for the next hour. When I begin to search for it I think “that’s what Grandma Gilbert would do.”  I will use the same hand mannerisms as my mother or work through a tough decision in a similar way that my dad would.

Ultimately you are your family.  In both nature and nurture. Not only do we, at many times, behave like our parents but we inherit part of their genetic makeup.  This is pretty common knowledge, right?  We expect our children to have similar hair or eye color as ours, to be of similar height, to resemble one parent or the other.  But you give more than just your dark hair or your hazel eyes to your kids and your pick up more than just your eye rolling and coffee misplacing skills from your elders.

We as gynecologists care about your family history.  Why? Because your risk of certain diseases, including cancer, could be increased based on your family history.  We know that about 5-10% of gynecologic cancers are hereditary cancers.  What is a hereditary cancer syndrome?  It is a genetic predisposition to a certain type of cancer so the patient is at a largely increased risk of developing a certain type of cancer and these cancers are often diagnosed at a younger than expected age.  When I talk to medical students about what I do every day, I tell them that one of the most important things I do is try and prevent disease. When I ask, “Do you have any family history of breast, ovarian, uterine or colon cancer” not only am I going to remind you about how often and when to screen for these diseases but if your family has been affected with these cancers we will talk about how you might be a candidate for genetic testing that could save your life.

For example, if your family history includes women affected with breast and ovarian cancer, you or your relatives might be affected with a BRCA mutation.  Or if you or your close relatives are diagnosed with uterine or colon cancer then my mind is on alert to think about Lynch syndrome testing.  When we identify women affected by a hereditary cancer syndrome we can offer those patients early and more intensive screening and in some cases even perform risk reducing surgery.  Every month we learn more and more about how cancer develops and discover better ways to treat and prevent cancer.

I have a cousin who was diagnosed with stage 4 ovarian cancer in 2012.  She’s pretty much a rockstar.  She spends her days running her nonprofit caring for patients and their families. You can check her out at http://www.tteal.org.  She is an advocate for early detection of ovarian cancer as well.  She is inspiring to me.  You can be an advocate as well.  You can advocate for yourself and your own family.  Learn your family’s history.  Talk with your physician.  Find out if you or someone in your family is a candidate for testing for a hereditary cancer syndrome.

You might still turn out like your grandmother leaving your coffee to sit in the microwave.  That wouldn’t be so bad.  But you might also find out you can reduce your risk of cancer by simply sharing your family history with your physician. Something to think about.

transparency in all things.

In the 6th grade I wanted to star in a musical on Broadway.  My favorite music at the time were the soundtracks to “Annie” and “The Sound of Music.”  This continued on for many years until I realized that some sort of musical and/or theatrical talent would be required for that dream to come true.  One memory I have from that time of my life is my Jr. High drama class.  Mrs. Means had us do monologues.  My favorite one to do was to recite Charles Finn’s poem “Please Hear What I’m Not Saying.”  It was written in 1966 and I remember feeling so cool memorizing and reciting it because it was so dramatic and thought provoking.  The poem is about wearing masks; fooling people into thinking you are OK.  Part of the poem is below.

I idly chatter to you in the suave tones of surface talk.
I tell you everything that’s really nothing,
and nothing of what’s everything,
of what’s crying within me.
So when I’m going through my routine
do not be fooled by what I’m saying.
Please listen carefully and try to hear what I’m not saying,
what I’d like to be able to say,
what for survival I need to say,
but what I can’t say.

Sometimes as a physician I feel like my patients walk in wearing masks.  Part of my job is to read between the lines.  To figure out what my patient isn’t saying.  To ask the right questions to find out the real reason why they’re here, where the fears lie, where the focus needs to be.   Sometimes I don’t know what someone is really worried about until the very end of the visit when I get the “oh and one more thing…”   That’s usually the most important thing.  Sometimes when you walk into a patient’s room you can just tell that there’s something more going on.  It’s a challenge to discover what it is and try and help them through it.

I get to care for a lot of wonderful people.  Some of them I meet for the first time when they walk into my office.  Some of them I have known for many years before they come to me for OB or Gyn care.  But some of my favorite people to care for are the patients that know me…but I don’t know them.  The patients that at the end of the visit tell me that their fiancé is someone I know or their mom is my patient or they know my husband, my family, etc.  These patients have taught me a lot.  It goes something like this.  Me: “Is there anything else you need or that I can address for you today?”  Them: “No, but just so you know I am married to so and so and they know you from such and such.”  Me: “Oh, how cool!”  Because they walked in the door as an “unknown” I treated them like any other patient I didn’t know.  I didn’t make assumptions about what they needed, how they felt, or hold any bias or belief about them.  And they have taught me to do the same thing for all my patients, even the ones I have seen for many years.

So, when you enter your doctor’s office, whether it’s your gynecologist, your cardiologist, your psychiatrist or your family physician…take off your mask.  Attempt to be fully honest.  Tell your doctor what it is that worries you the most, what you need the most, what you’re looking for.  While I won’t promise that we as physicians will have the answer or be able to give you what you want I can promise that we will be honest with you in return.  We will tell you what we can and can’t do…what we know in medicine to be true and what we just don’t know about your disease yet.  We will try to relieve your anxiety and your suffering.

This past Wednesday was Ash Wednesday.  At our church we assembled to hear how we could be shaped and transformed during the season of Lent.  At the end of the service we receive the imposition of ashes.  The ashes are placed as a symbol, a reminder, that we are a broken people in need of a redeeming Savior.  It’s hard to ignore a giant smudge of oily ash on someone’s forehead.  As awkward as it may seem, it’s kind of nice.  You don’t need to ask someone if they went to an Ash Wednesday service.  It’s clearly visible.  How would we feel if our most urgent needs were smudged on our forehead for the healers in our life to see.  Maybe we can all make an attempt to be more transparent.  In the doctor’s office and with each other.  I hope the next time you visit the doctor you remember my 6th grade dream to be on Broadway and Charles Finn’s poem and do your best to be transparent.

photo credit to zach lucero.

kms

 

1 in 3.

I am writing this post as we prepare to watch Super Bowl 50.  If you know Pastor Jason and I, you know that we love sports.  I mean, we love Jesus, our families, our jobs, and all that stuff. But we love sports.  One of our favorite things to do when we were in our first few years of marriage was to go to the NCAA Men’s Basketball Tournament every year.  We would travel to the nearest city with first round games.  We have been to see the Oregon Ducks football team play in several different states and (confession) our oldest learned most of her counting and math skills watching the scores change during a game.

So back to the Super Bowl.  As much as I love watching the NFL it always gives me this nagging reminder that domestic violence (DV) is a huge problem in our culture.  We don’t talk about it unless someone famous is accused and then we find ourselves watching the media’s commentary on the subject.

1 in 3 women will be the victim of violence by an intimate partner at some point in their lifetime.  No, seriously, 1 in 3. Every 9 seconds a women in the US is assaulted or beaten.  Now DV victims can be men, but I’m a gynecologist so today we’re going to focus on women, who are 4 out of 5 victims. Oklahoma is ranked 3rd in the US for women killed by men in single victim-single offender homicide.  DV costs our nation millions each year in lost wages and treatment of injuries for victims. The emotional impact on these women and their children cannot be adequately measured.

And unless you’ve been living under a rock, you probably know that the NFL has had several major incidents with DV in the last year.  First Ray Rice, a wide receiver for the Baltimore Ravens, we caught on tape beating his wife in an elevator.  The NFL suspended him two games when they heard of the accusations, then suspended him indefinitely once the public saw the gruesome footage.  (He has appealed, won and is eligible to play again).  Then defensive end Greg Hardy was accused of DV after an altercation with his girlfriend.  He told police that his girlfriend “fell in the bathtub.”  At the NFL hearing for Hardy, the defense attorney claimed that Hardy was the victim, and basically accused his girlfriend of being promiscuous.  A common defense for DV perpetrators is the thinking that women need to be “put back in their place.” After he was reinstated, Hardy was then signed by “America’s Team” the Dallas Cowboys where he has continued to make sexist comments and act violent towards his teammates.  And now Heisman Trophy winning Johnny Manziel has been accused of beating and threatening to kill his former girlfriend.

DV is something we should all care about.  You see, DV is not limited to women who are in relationships with professional athletes.  It is not limited to the poor, the black or the non-religious.  The National Coalition Against Domestic Violence puts it this way…

“Intimate partner physical abuse is not bound by age, socioeconomic status, race, ethnicity, sex, sexual orientation, gender identity, religion or nationality; it exists in all communities. Contrary to popular belief, physical abuse is not simply a mal-adjusted person’s occasional expression of frustration or anger, nor is it typically an isolated incident. Physical abuse is a tool of control and oppression and is a choice made by one person in a relationship to control another.”

Why do we have a domestic violence problem?  Lots of reasons, but probably the foremost is that we tolerate it.  We lack education and awareness.  We think of DV as a problem between 2 people, and fail to recognize it as a problem in our culture.  Deion Sanders characterized Manziel’s relationship with his girlfriend as “inflammatory” and that his problem is that he is in a relationship with her…I would argue that if the allegations are true Johnny Football’s problem is that he is a perpetrator of DV. We wonder how a women can’t “get out” when she is pregnant or had children.  We shake our heads at women for “staying with that guy” and fail to understand the social, economic and physical isolation that often makes it impossible to women to leave the men that abuse them.  We don’t understand that women who attempt to leave an abusive situation and are unsuccessful are often subjecting themselves to an escalation of violence and increasing their risk of being a homicide victim.  We make excuses for men who abuse women and fail to understand that no amount of wrong makes DV a right.  As a culture, a country, a community we fail to recognize that this problem belongs to us as well.

Can we love football and still work to eliminate domestic violence?  I’m not sure.  I hope so.  What I am sure about is that we will ALL encounter someone who is a victim of DV.  It might be the friend who becomes increasingly isolated.  It might be the woman who visits your church.  It could be your neighbor, your co-worker, your boss.  I hope we keep our ears and eyes open.  I hope if we see something we say something.  I hope we avoid the thoughts of “she should have…” and come to understand that victims of DV are just that.  Victims.  They need someone to be their voice, their shelter, their advocate.

So when you watch Lady Gaga sing the National Anthem or while you’re enjoying Cam’s “dabbing” or Peyton’s pizza commercial, don’t forget that we live in a culture that hasn’t found a way to end violence against women.  Don’t forget that you can do something about it.  Don’t forget the 1 in 3.

 

“when are you going to…”

 

So I have this friend.  I have known her since college but wouldn’t call her a friend until maybe the last 5 years or so. Our friendship has evolved in that time and I can honestly say that I like her more with each passing year.

We both have 2 kids.  Her oldest and my youngest are the same age.  She used to ask me all the time, “when are you going to have your 3rd baby?”  At first I would literally laugh out loud and roll my eyes.  But she would still keep asking.  Like ALL the time.  It just kept coming, the same question.  You see my friend can’t wait to have baby #3 and maybe #4.  She has a plan for when she wants them and her life after that.  I can’t imagine managing my life with another child, let alone 2 more. Pastor Jason and I with 4 kids is the stuff sitcoms are made of. Pure chaos I’m sure. I think for a long time my friend didn’t really believe me that I wasn’t going to have another baby.  And for awhile I was sure she was never going to stop asking me about it.

My friend challenged me.  While I was adamant to her that there was “no way in he##” I was having a third baby, and I had a hundred reasons why, I had to ask myself “was I at peace with that decision?”  You see, my friend challenged me to seriously examine what I wanted out of life, and be OK if it didn’t look like what everyone else was doing.  What will probably come as no surprise to you is that we live in a world where all of us are harshly judged for being stay at home moms, for being working moms, eating GMO or non-GMO, for having too many kids, no kids, not enough kids, and everything in between.  And we buy into the thinking that what everyone else is doing is what we were made to do.  We are looking for that one thing that will make us just as happy as our favorite “frenemy” on social media who we imagine has a life just that much better than ours.

Identity is an interesting thing.  We were all created to be and do different things.  I can’t wait to see her toting around her 3 or 4 kids, serving in church, encouraging others and finding ways to show her kids what is most meaningful in life.  Me, I’ve got research to do and papers to publish, podcasts to produce, medical students to educate and stuff to do at church with pastor Jason.  My two kids think it’s cool that mom “does surgery and gets the babies out” and “teaches the almost doctors” and that makes me proud.  I think Mother Teresa said it best.  I cannot do what my friend does and she cannot do what I do.  What were you created to do?  I hope this post gives you permission to examine your own life and ask yourself “when are you going to…” and fill in the blank with what you were created to do.  I am so thankful for my friend.  She inspires me and I hope I can challenge those around me with the same question.  So when are you going to…?  Together we can serve God, serve others and we can change the world.

we can do better.

Yesterday the US Preventative Services Task Force made a recommendation regarding screening for depression in adults and specifically addressed postpartum depression (PPD).  This is in alignment with the American Congress of OBGYN (ACOG) recommendation to screen women at least once during the pregnancy or postpartum period.  The official recommendation is below.

“The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”

Seems pretty obvious, right?  Women have babies and we should screen them for a disease that is twice as common in women as it is in men and can have devastating consequences for families.  But it’s more complicated than that.  One: we don’t talk about postpartum depression.  Two: we don’t allow women to admit when they need help.  Three: we don’t have good systems in place to give women with PPD the comprehensive care they needs.  And by “we” I mean us, as in you and me, Oklahoma, America.  All of us.

Postpartum is a really bizzare time.  You spend approximately 40 weeks, if you’re lucky, carrying another human being inside you.  You devote a large portion of your blood supply, nutrients and other resources keeping this person alive and growing them into someone that can survive in this world.  Then you give birth to them.  Which is a huge deal no matter how you do it.  Walk in and drop out a baby in 30 minutes, labor for 4 days, have a c-section…it’s all a big deal.  If you don’t get that, let me know.  I’ve got stories for you.  And then you get to experience the strange period of time called postpartum.  For those of you who’ve been there, you know what I’m talking about.  You sleep for anywhere from 30 minutes to 2 hours at a time, someone is always crying or needing to be fed, you are leaking fluid from literally everywhere, and you’re body is trying to figure out where that person who used to live inside you went. Weird, huh?  But baby’s here so we instantly forget that the mother existed and focus on the cute bundle of joy who’s drooling all over your shirt.  We don’t begin to consider that the mom might be overwhelmed, and for most it wouldn’t cross our minds that she would be depressed.  We can do better.

Our culture doesn’t do well with mental health conditions.  We see depressed or anxious people as “weak” and “crazy” and those that seek psychotherapy as someone who “can’t keep it together.”  If you have high blood pressure or diabetes you don’t get this flack.  We treat you with lifestyle modifications or medication or physical therapy for your conditions…your mental health should have the same priority as your physical health.  It should be treated with the same respect and compassion.  We don’t roll our eyes at people with cancer; we come alongside them in prayers of healing and hope and support then in every way we can.  Why can’t we do the same with PPD and other mental health issues?  Let’s start the conversation.  The USPSTF and ACOG has recommended we screen because we as physicians can make a difference by asking women about PPD.  The community at large can make a difference by accepting that women with PPD are no different than moms who aren’t affected: both of them care deeply for their families and want to be the best possible mothers.  We can do better.

I used a validated screening tool (EPDS) in my clinic for postpartum depression.  I haven’t always done it.  But then I had patients come back one or two or three years after having their baby and tell me about how they suspect they were suffering from PPD and didn’t know who to talk to.  So now I try to screen everyone I can.  But we have to work to create access to resources for these moms.  Yes I can counsel someone about the risks and benefits of taking medication for PPD.  But many moms just need a therapist, or a support group, or even just a community of faith or a community of friends to share the burden with.  I hope the USPSTF recommendations will encourage my partners in healthcare to increase our efforts to screen and treat women during pregnancy and postpartum.  And I hope that those of you outside of healthcare will lend a hand, share a story or take a turn holding a baby for that new mom. I hope that all of us have the courage to ask postpartum women how they are coping and be accepting of any answer they give us with a willingness to listen and help.  We can do better.

The picture above is me and some of my residency classmates (sorry guys) literally hours before I had my first baby.  I was a 3rd year resident training to be an OBGYN.  I thought I knew what I was getting myself into.  Now I look at that picture and see someone who had spent the previous 3 years working 80 hours a week and cramming her brain full of all the information it would hold…but had no idea how things were about to change.  I was a (postpartum) hot mess.  I struggled to care for my baby and certainly didn’t care for myself.  Fortunately I had friends and family who made sure I ate, slept and was wearing clean clothes (thanks mom).  That baby reminded me of what a vulnerable human being I was.  Of how much grace I needed. She is now doing multiplication and her sister is giving me sass about anything and everything.  I love them dearly and am grateful for the opportunity to experience the bizarre part of life we call postpartum with each.  But we can do better…let’s try.

kms