Pocket Wisdom

I was rifling through a box of papers from the days of my first few years of practice in the small town of Chemainus (1994-1998).    The beginning of learning how to care for patients and fit into the medical system.   I came across a folded up piece of paper that I recognized as one I had carried in my lab coat pocket for many of those early years…

Ode to Patient Care

If we speak with the tongues of specialists and consultants,

and have not love, we will have nothing more than the noise

of our own voices and the clanging of pet ideas.

If we develop new methods, write new curriculum,

and learn new techniques,

and if we understand all about the five stages of dying

so that we are not surprised when a patient is angry or depressed:

and yet we have not love, we are useless.

If we give up our old anxieties about talking with patients

concerning their true feeling,

but we have not love, we gain nothing.

Love never ends.

As for tumour conferences,

they will pass away;

As for workshops,

they will cease;

As for inservice training,

it will change.

For our methods are always imperfect

and our plans often don’t work out.

When I first became a helper, I thought like an idealist

and talked like an expert.

As I began to mature, I realized that I too was afraid

and the patient often taught me.

For now we see only reflections of sickness and death,

but someday we will see them face to face.

And the time will come when we will know for sure what it is like,

and we will be sorry we ever judged.

So methods, techniques, case conferences, care plans,

seminars, small group experiences, counselling-

There is all this and much more we would suggest for

gaining insight and increasing effectiveness:

But greater than all of these is love.

Dan McEver

Now posted once again where I practice daily so I can be reminded of what really matters….

Love Matters

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I had an interesting conversation today with a teacher as I was giving her a flu shot.  When I asked her what grade she taught, she said she taught grade two and went on to tell me that she felt lucky everyday to come to work.

How often do you hear that?

She told me that she really loves her students, but went on to say that maybe she cares too much, becomes too attached to her students and maybe that wasn’t such a good thing.

I told her I actually thought the opposite was true.

The more you care about those you serve, the more you know them, the better you are able to teach them.  When a child feels that you actually care about them, can depend on a connection, they are more apt to listen, be more open to taking risks in their learning and stretch to meet expectations.

Love matters.

For me, it’s the patients for whom I’ve stayed up late at night researching drug therapies for, those I’ve called to see how their chemo is going, how their son’s depression is, and those that I’ve checked on by email when I am away; the connections I have with those patients make me a better practitioner.  They remind me that the better I get to know a patient, the more I know about their family, what matters to them, how they feel about their health and other matters in their life, the better able I am to advise them, help them make decisions regarding their therapy and teach them how to manage their illnesses and disease.

Love matters.

If you love what you are doing, ultimately you are happier.  If you are happy in your life’s work, whether it’s education, health care or other pursuits, you will do a better job.

As that teacher walked back to her classroom I thought, “That’s the kind of teacher I wish I would’ve had as a child.”

“What have I done?”

A few weeks ago a colleague warned me that in the first year of owning and running a new pharmacy I would conclude that I had made a huge mistake.

Yup….that happened well before turning the sign to “open”!

The two weeks leading up to my opening day were chaos.  I’ve never slept so minimally, had my “to do”list grow so fast, nor seen my children so little.  As I heard repeatedly, “Mom, are you coming home late again today?” I figured I had made a mistake.  I am a clinician; I love the “care” part of health care, and here I was, steeped in putting a business together. Spending hours on end away from my family, and even when with them my mind was racing with all the things I needed to handle.

So when I walked into my brand new pharmacy on day one and flipped the sign to open, I wondered whether I had jumped into something I would resent, or at the very least not enjoy.

Then came patients through my door.  Just a few at first, and a few more each day, and I found myself in a place of privilege.  As I provided health care, I heard their stories.  Stories about caring for terminally ill spouses, stories of how difficult it is to live with chronic pain, journeys through chemo and disappointment with the system.  Even stories of past jobs and places they had visited in their life time.  As I immunized many against the flu I also shared a lot of my own story.  How I came to be in this new pharmacy, growing up in Saskatchewan, how I had started a pharmacy in Chemainus when I was very young.

It struck me once again that the connection made and the care given are what brings me joy.  Having my own pharmacy means I can structure and set up to practice the way I want.  I have control over how I care for the people who walk through my door.  There is no one to tell me I must meet a certain quota or promote sketchy treatments or unproven products.  In the end, it is worth all the headaches that I am sure will come.  So it is to the people who came through my door this week that I am grateful to, for reminding me what it’s all about.

Tidal Wave Changes

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For the first time in 8 years I am not homeschooling any of my children, and after 18 years of practicing pharmacy in someone else’s dispensary, I will practice in my own.  I’ve made a huge leap, with the support of my family, into what I hope will be a rewarding new phase in my personal and professional life.

Those who have read my blog, or visited my professional site, know that I have complained a little (and sometimes a lot) about the struggles of wanting to practice pharmacy in line with my philosophy of patient engagement and focus on learning.  So I’ve made the leap to “putting my money where my mouth is” so to speak and, along with some great partners, am opening a pharmacy in Stony Plain.

As I embark on an exciting new phase of my career, my children have also had to adapt and grow.  They have taken on full time school (here’s Noah’s remarks on that), more chores, my babysitting,  and a different way of learning at home (less time with Mom to explore cool stuff together.)  My spouse has moved his office home to be more available to them and they have embraced the changes with more enthusiasm than I had hoped.

I’ve experienced, over the past year, small ripples of growth and change and had no idea where they would lead.  As the ripples converged into a wave, I’ve received much support and encouragement from family, friends and global connections.  I have much to be grateful for. And yes, even though I’m sending them all to school, on their first day they still got cake for breakfast.

5 “Must Ask” Questions about Your Prescription

When you are handed a prescription by your physician or your pharmacist there are many questions you should know the answer to before walking out the door. Below I highlight my top five.

CC Flickr Shared by Rob!

  1. What is this medication for?

This may seem obvious, but countless times when I ask a patient if they know what their prescription is for they tell me they have no idea.  When someone doesn’t know what a medication is for, there is little motivation to take it correctly or even at all.  Most drugs have more than one indicated use.  Know what yours are being used for.

2. What will happen if I don’t take this medication?

This may seem a strange question, but the reality is that over 50% of medication prescribed is either taken incorrectly or not at all.  (Health professionals are a little vain- we tend to think if we prescribe it, you will take it.) If you don’t take your high blood pressure medication, you have a higher chance of having a heart attack or damaging your kidneys.  If you don’t take an antibiotic for a nasty cold…well, really nothing is going to happen because antibiotics do not work for colds.  There are many prescriptions that are unnecessary or could be avoided with “watchful waiting” and there are some prescriptions that can be deadly if you do not take them exactly as prescribed.

3.  When can I expect this medication to work for me?

An important piece of information.  Will it treat my problem/condition in an hour or in 2 months?  Knowing what to expect is essential.  Someone being treated for clinical depression needs to know that the medication they are getting may not start to work for 2 to 6 weeks.  That’s a long time if you are expecting to feel better tomorrow.  Equally important is a person in acute pain to know that the pain medication should start working in an hour or so.  If not, it may need to be adjusted.  And if after 3 days of antibiotics your skin infection is spreading, don’t wait for the ten days of pills to be over.  You need to be reassessed right away. Know what to expect and always ask questions if you are unsure.

4.  What do I do if I have a problem with this medication?

Not all problems or side effects require another appointment.  Many issues can be solved by tweaking the dose, timing, formulation or way of taking the medication.  Sometimes a change of medication is necessary.  Find out what some of the common problems or side effects of your medication are and what you can do about them if they happen.

5.  Can I take this medication with all my other medications?

I find that most patients will ask me about this.  What is often missed though are the non-prescription medications, vitamins or herbal products they are taking.  Patients tend not to mention these as they are often viewed as “safe” and not harmful.  But in fact, there are many vitamins and “natural” products that can interact with prescription medications.  It is important to mention them all.

We all know it is impossible to remember everything your doctor or pharmacist tells you.  And that is where follow-up and communication comes in.  When I see a patient I advise them of any follow-up that is needed or how to reach me for questions. Typically by phone or email, but for more complicated learning I’ll see the patient in the office. Whether your nurse, pharmacist or physician provides you with your prescription, ensure you receive proper follow-up and educate yourself.  You are the person with the most vested interest in your own health.

Balancing the Scales…or Not

A friend of mine sent me pictures today, taken at my 40th birthday party.  Yup, I turned 40.  And while that could be a post unto itself (many who know me are no doubt nodding their heads, remembering all the complaining leading up to that number!) what I really thought about when I saw the pictures was the relationships with the people who came out on a very stormy night to help me celebrate.

A very eclectic group shared the transition with me.  My spouse who pulled off the grand affair without me knowing, friends who’ve known me for years, people I’ve only known a short while, family, hockey parents with whom I’ve sat many hours in cold arenas with, staff who’ve run the gauntlet with me, and teachers who’ve taught my children and become great friends.

It’s to the last that I thought about today.  These educators who I’ve worked alongside with, who I’ve learned so much from, yet who have treated me as a peer.  We’ve had a unique relationship being co-educators of my children.  It has been unbelievably valuable not just for my boys, but for me, to be involved in this type of educational structure.

That night they had a presentation for me which included putting on the screen a quote from a blog post I wrote for the school division.  (I hadn’t posted it on my personal blog until today.)  And they asked me to read it aloud to everyone there:

I take my personal learning quite seriously: connecting to other educators on twitter, reading widely and often debating both Education philosophy and practice. But if I am honest, I have learned the most about education from my sons, and have incorporated those lessons into my own learning. Following my own passion in both Education and Health Care has made me a better practitioner in both areas.  Thank you boys.

Reading the words I had written only a few months ago, out loud to a room full of people I care about,  was surprisingly emotional for me.

Seeing the pictures today reminded me of why I keep walking the tricky balance between two disciplines I love (Education and Health Care).  I say tricky because it is sometimes impossible to find a balance;  the scale tips one way or the other.

As I’ve branched out and become more engaged in my professional life I know it has put strain on lesson planning time, time with my kids and my personal life.  And vice versa, when things get busy with teaching my boys and we’re digging into some great learning, my professional time slides and I can’t devote as much to patient care.

There are some days I think it would be easier to reduce the focus and drop one.  And I know this is an ancient struggle, especially for working parents, but today I was reminded why I do it…. and that it is worth it.

E=

cc licensed flickr photo shared by chrisinplymouth

E = EXACT

Health Care is not an exact science.  That’s right.  We want it to be…and I see much frustration, disappointment and even desperation because of this fact, but it’s the truth.  Despite all the medical advances and advertising of drugs that seem to point to the opposite, there really isn’t a “pill” for every illness or a test to diagnose every medical condition.  Sometimes there is no clear cut answer to a health problem, nor a solution.

Medicine and Pharmacy are applied science which means we take science and apply it to people.  We take everything we know about anatomy, microbiology, pharmacology, biochemistry, therapeutics, etc., and apply it to individuals who have their own unique physical, biological and genetic differences (not to mention the social, cultural, and psychological aspects).  From this application of knowledge to each individual situation, diagnosis is made and treatments are decided upon.

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E = ERRORS

This applying of science also means that medical care is not perfect.  Combine that with the speed at which this knowledge needs to be applied to patients and situations, errors are inevitable.  Here’s a quote from Dr. Brian Goldman that had me thinking this week.

What I’ve learned is that errors are absolutely ubiquitous. We work in a system where errors happen every day.  Where 1 in 10 medications are either the wrong medication given in hospital or the wrong dosage…  In this country as many as 24,000 Canadians die  [every year] from preventable medical errors. [which is a gross underestimate]

We all know someone who has had sub-optimal medical care or errors made in their care.  Often there is anger towards the professionals that made the mistake.  I’ve been on both ends of that situation.

There is an expectation of perfection in health care.  As patients we expect our health professionals to be competent, and so we should.  But as a health professional I know we are all human and lack perfection.  We all fall short and can make mistakes.

I’ve made mistakes in my career and will most likely make a few more before I am done.  Fortunately I have never made a mistake that has seriously harmed someone or caused a death.  But I know each time I put my lab coat on it is a real possibility.

cc licensed flickr photo shared by chrisinplymouth

E= e-PATIENT

The possibility for error is why I continually encourage people to be engaged in their health care.   Not because you shouldn’t trust your health providers.  Quite the opposite.  You need to be an active partner so a trust relationship is essential. Working as a team is the best way to ensure optimum health care.  How can you do this?  Get to know your own body, your medical conditions, your medications.  Ask questions. We need you to be as educated as possible.

More and more patients are getting health information over the internet.  (Interestingly, Health Professionals are often divided over this.  Some thinking this is great and others not so much).  I think the more knowledge you acquire about your own health the better.  And this is where the trust relationship comes into play.  Yes, there can be some bad information out there.  So you check it out with your doctor or pharmacist.

Last week I had a patient in tears because she had read on the internet that her diabetes medication could give her seizures and she didn’t know what to do.  Was that good information?  No.  It wasn’t true.  But I didn’t advise her to stay away from internet health information.  I provided her with some reputable sites and encouraged her to learn more about her disease and contact me in a week to go over what she had learned.   As one e-patient says in this video, “When push comes to shove you check with your [health professional]. They’re there for a reason”

Here’s an example of the growing movement of “e-patients.”  As you’ll see, the “e” stands for many great attributes that can lead to a safer, more participatory, less paternalistic model of health care.

Uninvited Gift

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It’s been five years since she was told she was “cancer free”. Today she was told it was back, and the future was quite grim.

My job was to make sure she understood how to properly take the medication that would reduce the swelling around the tumour so radiation could start as soon as possible.

That was my job. Clinically speaking it wasn’t the most challenging or difficult issue of the day as I scanned her file. Then I went to speak with her.

It took mere minutes to make sure she understood how the new medication worked, how to fit it into her day with her other medications, how she might feel taking it. We reviewed her other drugs and medical conditions and I assessed her level of understanding to be high. Job done.

But what about the other part of my job? When she told me about the cancer returning, I looked into her eyes and could see the shock… and the fear. What she needed in that moment was human connection; a hand on hers and someone to listen to her.

When I looked around for the time I needed all I saw was the impossibility. At least a dozen patients waiting for me to sign off on their medications, one waiting to learn how to use their new inhaler, and two patients nervously waiting for me to administer their injections. At the same moment I heard one of my technicians say I was wanted on the phone by a physician.

Time…..I didn’t have it. I couldn’t take her into my office and be that presence for her.  So I spoke medication, touched briefly on the agony of the diagnosis, and resisted going too deep.  I know too well the fragility of emotion, and without the privacy to truly be present to her situation, she needed to keep from falling apart and make her way home.

But somehow I feel I have failed. There have been times when I have taken patients into the office who have been grief stricken, going through withdrawal, requiring in-depth discussion of an issue…. But today, I was stretched too thin.

And so…I take it home with me.

I have had colleagues tell me to leave the job at the door. Walk away to my family and rest assured there will be more patients and problems tomorrow. I have learned that at times I can and must do it, and at other times I simply can’t. But perhaps it’s the “can’t” moments that make me a better professional…..a better person. There are times when I experience humanity laid bare….a rawness of emotion, a fragility to life. These experiences become a part of me whether I invite them in or not. In the end they are an univited gift.

Dr. Oz and the Ruby Slippers

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I really wish Dr Oz would just put on his ruby slippers and go home. Just click those heels three times and retire.

That may sound harsh, and I usually don’t make such blanket statements, but honestly, he’s starting to do some real damage.

Like Oprah, when Dr. Oz speaks, millions of people listen. His level of influence in the average North American household has become almost iconic. Millions turn to him for advice. That would be a good thing if he was a health professional with integrity and his advice was backed by science. The reality is quite the opposite. Here’s my beef with Oz.

Dr. Oz puts profit before people.

When Dr. Oz first started out on Oprah, his information and health recommendations were fairly standard, typical of your family doctor with some Hollywood spin. Over the years, however, he has become more “Hollywood”and less “doctor”. He sensationalizes medicine, often offering quick fixes with unproven therapy. It makes for great sound bites (like the un-workout workout) and it sells, but it’s not based on science. In fact, coming soon is his own product line of unproven supplements. It doesn’t matter that he lacks the science to back up his claims. His name sells and so will his unproven products.

His advice can be dangerous

Diabetes can be prevented with vinegar and coffee. Really? If that were true, I know many of my patients would be reaching for more pie; just add a cup of coffee and it’s all good. Instead, what is proven by science is that weight management and good nutrition can delay Type 2 Diabetes.
If a person needs to lose weight to reduce their risk of having a heart attack or stroke and Dr. Oz says all they have to do is take white kidney bean pills and they can eat all the cake they want…that’s dangerous.
How about having a doctor on his show that believes cancer can be cured with baking soda? Not kidding.

Dr. Oz presents “Pseudo-Science” as fact

Pseudo-science is presenting a claim or belief as scientifically valid without having the scientific supporting evidence. Here’s what we mean by science:

What we mean by “science” is simply rigorous methods of observation. Good science looks at all the evidence (rather than cherry picking only favorable evidence), controls for variables so we can identify what is actually working, uses blinded observations so as to minimize the effects of bias, and uses internally consistent logic. Steven Novella, MD

Are there some studies showing coffee has an effect on diabetes risk? Yes. Can we use these studies to make sweeping statements that affect people’s health? No. That would be irresponsible. All that is proven by a few small studies is that more studies in that area need to be done.

Dr.Oz takes “bad science” or limited science and presents it as fact. That’s irresponsible.

I’ve been in health care long enough to see really good studies point to facts that we incorporate into our practices as health care professionals. But 10 years later (after more studies with larger numbers of people, going on for a longer time), the original studies are proven to be misleading or even point to the opposite conclusion. Studies need to be examined with the eye of a sceptic and there is a science in itself to evaluating the strength and validity of scientific studies.

When people come to me with health concerns looking for advice, they are in essence sharing a trust. Patients expect me to be honest and to have their best interest at heart. They expect that my advice will be based on scientific evidence, not on anecdotes, popularity or profit. Patients should expect that from all their health providers.

Dr. Oz fails on all fronts. So, Dr. Oz, if the ruby slippers don’t fit, perhaps you can take the job of the original Oz behind the curtain. After all, he was a charlatan too.

All I Want for Christmas…

Gratitude.  It was top of my list for Christmas this year.  To feel more grateful for the life I have, to not need more, to feel settled and ultimately at peace.  So while I sit in my quiet house, the chaos of the day having quieted down, the gifts I have asked for have arrived.

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The past two months I have had several close friends suffer serious health problems.  All of them went from lives busy with work, kids activities, holiday plans….  then everything in their lives suddenly came to a grinding halt.  When your health fails, that’s all that’s on the plate.  So, I am grateful for my health;  so far my life continues as is, and I wish to not take that for granted.

Working in the inner city once more this week reminded me of how grateful I am for my parents.  I am fortunate that they had no drug or alcohol addiction, no mental health issues or extreme  poverty.  They managed to make things work and keep our family functional and enriched.  It allowed me to develop and grow and have a “normal” childhood, unlike so many in our city.

I am grateful for my education.  My parents somehow instilled in us the importance of furthering our education.  It was not an option for us to learn, our only choice was what to learn about.  It continues to lead me in my career and to passing on that value to my own children.

Lastly, my gratitude falls to those who are closest to me.  There are people in my life who know the good in me and also the not so good in me….yet still choose to love me.  They are the ones who make life beautiful.  You know who you are.

Merry Christmas