Reflection on a Monday Morning: Roll With It.

*written with permission of my brave and smart patient, Mr. M. - thanks.

Sometimes you just have to roll with it.

"Every time I move my bowels, I see a whole bunch of blood. Like everywhere."

"That must be pretty alarming."

"Yeah, it is, doc. The whole bowl turns red. . .and then later on, I'll just be sitting there minding my business and next thing I know, the whole backside of my pants is soiled with blood."

"Wow."

"Yeah, doc. It's bad. I saw somebody one time in the clinic and they set me up for a colonoscopy, but I never went."

"Why not?"

"Honestly? They scheduled me for a whole bunch of stuff that day. . . . .the eye doctor, the colonoscopy, nutrition. . . .so I mixed up the eye doctor appointment with the colonoscopy."

"Oh man."

Laughing. . ."Yeah. . . .you know how mad I was when I drank that whole gallon of Go-Lytely for a eye doctor? I was mad has hell!"

"Oh no! You drank the bowel prep? Before the eye appointment?"

"Every drop, doc!" He chuckled softly and then suddenly looked serious. "Yeah, every drop."

"Hmmm. Are you ever constipated?"

"Whatchoo talkin' bout, doc?" he teased while raising one eyebrow. I smiled back, familiar with this slang equivalent to definitely. He shook his head and went on, "That's an understatement, doc! I stay constipated. . .but every blue moon, it'll let up."

"I see. . . .well, you know that straining puts you at risk for hemorrhoids. That could definitely make you bleed."

"And fill the whole bowl up with blood?"

"Sure can."

"Wow," he said while looking away. He drew in a breath, "but you know what, doctor? Something in me makes me feel like it ain't just hemorrhoids."

Therein lies the problem. To me, for the most part, it did sound like hemorrhoids. Regular old hemorrhoids. But here he was. Sitting in the Grady emergency department telling me, literally, that he didn't agree with that assessment.

"Sir, when was the last time you saw a doctor? Like when was that clinic visit you missed?"

"It was 'bout six, seven months ago. I lost my job close to that time, and you know, I stay in the shelter now, so it's kinda hard to get around."

Damn. My fleeting thoughts about how to get him evaluated as an outpatient began to flutter away. . . . I looked at him carefully. Well-developed, well-nourished. Neat, clean clothing and a pair of running shoes. Hair, neatly groomed in a military style buzz with a hairline that, even in his sixth decade, was not being threatened by male pattern baldness. Rich brown skin and a meticulously groomed goatee framing smiling teeth that appeared to be brushed regularly. Clipped nails, a working watch. This guy his homeless? Damn.

"You became homeless after you lost your job?"

"Sort of. It's kind of messed up, doc. I'm a college graduate and I had a great job. I, unfortunately, got mixed up in drugs at one point. . . .crack. . . .but I got in rehab and was clean for like ten years. Was doing well, had me a good job again and everything. Then this economy went crazy and I got laid off. Man, I was so depressed, doc. Lost all my benefits, my house. . . .I got weak, man. I relapsed. They let me back onto my job, and don't you know I messed it up?" He looked down and sighed.

I quickly looked down at my billing card to see if anyone had mentioned substance abuse. I wasn't aware of that piece of history. "Wait--you are using crack. . .like currently?"

"Ain't gon' even lie, doc. I used a couple days ago."

I could feel my blood beginning to boil. Not because I was mad at my patient. I was mad at crack. I hate crack. Just hate it. It's like this horrible, ruthless bully that enters entire communities like gangbusters. . . .wielding a big gun and a machete and taking down everyone and everything and everydream in its path. I. Hate. Crack.

Next thing I know I was caught in a daydream of myself as a Power Puff Girl. . .flying through the air fighting off crack, one rock at a time. Knocking out dealers with a speedy forearm to the head and whisking every addict off to some safe crack-free shelter.

"Miss Mannings?"

I snapped out of it and looked back into his brown eyes. "Yes, sir."

"In my heart, I feel like this is more than hemorrhoids. I really do."

His hemoglobin was borderline low, but not scary low. Most people with bad causes of rectal bleeding have low blood counts. . .and they don't usually look this healthy. But how can you ignore what a patient who rarely sees doctors is telling you? I thought about the whole picture: unstable housing, crack cocaine use, and of course the history. I reviewed all that he said in my head. . .the bleeding with bowel movements and the feeling that this was something more. The only things that made me take pause were this strange report of soiling his pants with blood after a bowel movement, the fact that he had missed a prior colonoscopy, and the knowledge of him being homeless.

Near normal-ish blood count. Normal blood pressure. Clearly educated. Robust health overall. Previously lost to follow up. Enough bleeding to bring him to the busiest ER in Georgia. Hmmm. Should this guy really be admitted to the hospital or not?

This is one of the most common conundrums we face at hospitals like Grady. If every duck was in a row, you could probably feel okay about setting up everything as an outpatient. Make an appointment for an outpatient colonoscopy first thing next week, right? But what about when a patient has no phone number, has no resources, and already missed one colonoscopy? And what about when 90% of the story sounds like something non-lifethreatening, like hemorrhoids in a dude who's been constipated for, like, ever?

Oh, and what about the crack cocaine part? Do you shrug your shoulders and say, "What difference does it make? Even if this guy has a mass in his colon, it's not like he can be counted on to follow through with the demanding course of colon cancer treatment with a drug problem, right?" I mean, that is a real possibility. Not even far-fetched in the least.

So you make a decision. And you hope it's the right one.

We decided to admit this patient for his colonoscopy that day. He hadn't eaten breakfast, so the gastroenterologists were able to perform the procedure later that afternoon. (He was a champ and drank the whole gallon of GoLytely by 11 a.m.)

I completed his discharge papers the following day:

Assessment:

1. Rectal bleeding, secondary to Primary Adenocarcinoma of the Colon
2. Mild anemia, likely secondary to #1
3. Crack cocaine use.

Plan:

1. Adenocarcimona of the Colon limited to bowel only. Seen by colorectal surgeons
and oncology service for resection and neoadjuvant chemotherapy. Follow up
in Cancer Center this week. Appointments scheduled.
2. No indication for transfusion at this time. Initiate iron therapy.
3. Given resources for substance abuse treatment, counseled on cessation.
4. Pray. (Okay, I didn't put that in my note, but I thought it.)



What I learned from this situation:

• When patients say that something "just isn't right", listen.
• When one part of the history is odd, like soiling your pants with blood, listen.
  
• Look at the whole picture.
• Listen.
  
• Recognize when you're in a position to advocate for a patient with just the stroke of an ink pen.
• I still hate crack cocaine.
• Even though I hate crack cocaine, even those who use it deserve the benefit of the doubt.
• And most important, even when you patient uses crack cocaine, is homeless, missed their last appointment, and even when what this same patient thinks isn't exactly what you think--regardless of all of this--sometimes you just have to roll with it. Because many times the patient is, more often than not, right.
  

What would you have been thinking in this situation? What would you have done?

Reflection of an Error-Prone Human Doctor on a Sunday: The Good,The Bad, and The Indifferent

"I'm only human
of flesh and blood, a man.

Human. . . .
. . . born to make mistakes."

- from Human League's "Human"

_________________________________________________

Sometimes things go wrong in the hospital. Something happens that you didn't want or expect, and as an involved caregiver, you sit there scratching your head or clutching your chest or wiping your tears because of it.

Sometimes it's because of something you did or you didn't do. Yep, I said it. Sometimes doctors make mistakes. Foul ups, bleeps, and blunders that many times fly under the radar, but other times become headlines on the CNN newsroll. This is not unique to Grady Hospital, at all. This is a universal truth that is no stranger to any hospital anywhere and one that, no matter how much we want to pretend isn't true. . . . .just is.

Now let me also be clear that what I deem as a mistake can be as small as telling a hospitalized patient that their test is at 9 a.m. when it was really at 8 a.m. (which depending upon what that test is might not be "small" at all) or as big as amputating the wrong leg. Fortunately, medicine has evolved a great deal, and many more measures are taken to avoid the whoppers (such as amputating the wrong limb.) But again. . . .the Institute of Medicine put it best in the title of their landmark paper: "To Err is Human." Doctors are humans. And humans . . .well. . .humans sometimes make mistakes.

My mentor, friend and fellow Grady doctor, Neil W., has an expertise in medical errors. We were talking recently during one of our mentor/mentee meetings about what happens after an adverse event or error in a teaching hospital. Our verdict was that, most of the time, it's handled pretty crappily. (Yes, I meant to use that word.) Either it is ignored, the person is berated, or the really common one, there is a discussion that seems to focus more on how "the system" plays into errors and adverse events to the point that the assailant gets off the hook.

But sometimes, a person just made the wrong choice. Sometimes they were supposed to do one thing, like say. . . .come back to check on a patient again. . . .and they didn't. In such situations, it isn't "the system" at all. Is it?

So here's the burning question:

At what point is it just your fault?

Bob Wachter, the hospital medicine guru/coiner of the word "hospitalist," and all around hospital medicine bad ass, wrote a lovely article about this very thing. He talked about physicians and accountability (or lack there of). . . and how at some point, (depending upon the error) folks are going to have to just own the blame for what they did or did not do. Period. A much less warm and fuzzy approach than the "it was the system" theory, but definitely one that made me take pause.

So Neil and I started chatting this day about working on better ways to process errors and adverse events with our learners (and ourselves.) From this chat we ended up putting together a lecture for our residents and medical students about that very topic. It was really well received.

This made me realize a lot of my own shortcomings both as an error-prone human (or you-man, if you pronounce it like Neil W.) and as a supervisor of other error-prone humans. I recognized my prior default over the years when I had a part in an adverse event: self deprecation. I'd always have this internal recoil where I'd replay something over and over again . . .repeatedly cringing and demanding of myself with disgust, "How could you not have fill-in-the-blank" or "I can't believe you fill-in-the-blank." Then there's the learners. My go to response for dealing with learners who have fallen short has admittedly been: "You're still a wonderful doctor. . ." followed by a launch into all of the system things that could have caused something to happen. Yeah. The system.

The more I listened to Neil that day--and to Dr. Wachter in that article--the more I knew that my approach to processing medical mishaps needed to be revised.

I know. . . the goal should really be to avoid mistakes altogether, right? Since we know they can and will happen, another acceptable goal is to make every effort to not repeat the same mistakes. This starts with learning from them, and learning from them starts with owning them. You have to own your part in an adverse event instead of chalking it all up to the system. . .otherwise, the take home point that you were supposed to get will be lost in the shuffle.

The other tricky part is that you want to learn from the whole thing, right? Like, sometimes you did some really good things but had a misstep at one point. Sometimes you did several suboptimal things and got lucky. That's why processing our individual part (and not just that of the team) in events that take place with our patients is so important. We have to find that place where we own our piece--the good, the bad, and . . . .well, the indifferent.

A few years ago, I had this patient who was very, very ill. The patient was in the stepdown ICU with complications of advanced AIDS, and we were treating him for a condition that could be life-threatening. He was turning the corner, and I spent several hours taking care of him and building a rapport with his family. At the close of one of the days I cared for him, I walked out of the hospital feeling extremely proud of the care my team had offered him, and even more happy with his improvement.

The next morning, I was walking into the hospital and overheard a code being called on his floor. When I reached the floor, there was the characteristic pack of doctors and students pouring out of the unit, swarming near the doors. I asked a couple of residents what was going on, and they told me that the person who had coded was indeed my patient. "But the critical care team has it under control," they told me. "He's been intubated and should do okay from what we saw." Whew.

Right before I started to enter the threshold of the stepdown unit, I heard my patient's family calling my name. They were crying and screaming and very upset. They ran up to me and clung to me. They even squeezed my hands and included me in their circle as they prayed for him boldly and loudly--not in the hushed voice that I often use when praying.

"Is he going to die?" his mother pleaded with me. "Is this it? Is the Lord trying to take him home? Oh please, Jesus! Please! Tell me. . .am I losing my baby?" She was shaking like a leaf; terrified at the thought.

All I had to go by was what those passerby residents told me. The mom in me imagined burying one of my sons. No, he will get past this, I told myself. I made a choice and started talking. I looked my patient's mother dead in her eyes and said:

"No, he isn't dying. He is sick, yes. But they have him on a breathing machine and the doctors who work in the ICU got to him very fast. He is still young and is a fighter. He is sick, yes, but you are not losing your baby."

I looked her dead in her eyes and said this. And it was a tremendous comfort to her, and this whole family who, before I began speaking, thought he was dead in their eyes.

Two seconds later, the doors whooshed open and the ICU came out looking very somber. I thought I would vomit the second I saw them. The first words from the ICU fellow:

"We are so, so sorry."


Damn. I told this family something that was completely untrue. I took a family on the brink of the horrible tornado into it's calm center through my unsubstantiated yet comforting words. . .only to see them dragged straight back into the twister again with the truth.

My patient had died. I told his family--no, his mother--that he was okay, when he wasn't. I didn't go see him for myself before saying that. I should have entered the unit and seen, for sure, what was happening with my patient and I didn't. I screwed up.

When his family collapsed to the ground crying, trembling, praying. . . .I wanted to disappear. It was awful. I wished so bad that I hadn't made things harder for them.

But now, I reflect on that differently. I should not have based such sensitive information upon a drive by account from two house officers who weren't even involved in his care. I should have told the family that I would be right back--and spoken to them after confirming his clinical status. That was a bad move on my part--and although it isn't as egregious as pushing the wrong medication into an IV line, on some levels it was just as hurtful.

This time instead of reflecting only on the bad, I also recounted what good things took place, too. He was diagnosed promptly, received standard of care treatment and therapy, and had nursing staff that responded quickly when he took a turn for the worse. I established such a great comfort level with this family that they felt safe enough to call my name from across the room, weep into the shoulder of my starched white coat, and pull me into their unapologetic petition to God before I could even process whether or not it was appropriate for me to do so. They treated me like a trusted family member--a distinction I achieved after only two days of caring for him in the hospital. I think that the approach I used in getting to know them provided a comfort to a patient and his family during a tough time. I learned that in the future, I can use those same skills when caring for my hospitalized patients, but must always remember the importance of having all my facts straight before opening my mouth.


Now I see the whole picture, instead of just the reciprocating horror flick of the family breathing a sigh of relief followed by the mob of ICU doctors emerging through those doors with their morose "somebody just died" expressions. The truth is that I took good care of a patient, but at one point in his care screwed up. That wasn't about "the system" either. That mistake was about me.

Ah hah.

Lord knows that this doctor is certainly a work in progress. But I can honestly say, I owned my part in that mistake. I learned from my part, and will make every effort not to repeat it. Now, through this exercise of processing all dimensions of what happened, what I know for sure is this:

With regard to this patient,
There was something I did that was good.
There was something I did that was bad.
But at least I can proudly say it wasn't because I was indifferent.

Rapid Reflection After A Rant: On Second Thought. . . .

. . . .Okay. As Zachary would say, "I 'pologize."

::sigh::

To those (medical students and interns) who read the original version of my Generation Y rant (8/25/2010). . . . .sigh. . . .forgive me for coming across a bit harsh. My mom always says to me, "Write it, read it through, and then sit on it for a day," but for some reason I just can't ever bring myself to do that. (Now mostly she is talking about typos and grammatical errors, but still, it's a good point.)

I think I might've been a little too honest in that post. . . . . .

The version that's up now is slightly different. . . .I removed the part about "what we are really thinking" because upon further reflection. . .I think it just might have been too much information. (I'd prefer for y'all to think forever more that all of the thoughts that we attendings have in our heads are ultra polite and ultra understanding.)

The point of it all was to get people thinking about the people who dedicate themselves to teaching you--not to make you feel bad. Oh yeah, now I will also add that quite possibly, I'm the only one who thinks that someone might have felt bad . . . .but that's enough for me. This thing is called "Reflections of a Grady Doctor" after all. . .and that epiphany came after just that.

If you did not read the version of that post that I had up for approximately 12 hours (and according to my hit-counter, 93 of you did in fact see it), then good. If you read it and you weren't anything more than amused, then double good. If you opened the page that day, and realized it was an error and that you don't care about this blog, in this instance, I'd say that's good, too (although I'd be wondering now what you're doing reading this now. . .)

Take home point? It's simple:

Be nice. Be considerate. Be reasonable. Be mature. (And I will make every effort to do the same.)

***

"Is that a good 'pology?" ~ Zachary, Age 3

Early morning Haiku on a Thursday before Going to Grady: Priorities

Waiting for school bus

Mommy first, and then doctor

Have to keep that straight. . . .

Reflection on a Wednesday: To the Generation Y Learners with Love

*Disclaimer: This is a slight rant. If you are easily offended, please skip this post as I have much touchier, feelier offerings for your reading pleasure. . .

You DO realize that we can hear you, right?
_____________________________________________

"To all the learners that we've taught before

Who traveled in and out our doors

We're glad they came along

We dedicate this song

To all the learners that we've taught before. . ."


(Remix on Julio Iglesias and Willie Rogers' "All the Girls I've Loved Before")
_____________________________________________________

I started medical school in July of 1992. Back then, we called every doctor "Dr." and were so formal and deferential that you'd think it was a military academy instead of medical school. Although the internship I started in 1996 was slightly more relaxed, we regarded every faculty member highly, and never dreamed of anything that might come across as overly familiar or presumptive--especially when it came to our attendings and their time. Now, I'm not saying that there aren't students and residents who hold their attendings in the same esteem now. . .but sometimes. . . .just sometimes, it seems like the culture today in medical education is different than it was back then. The Generation Y learners seem to have a certain chutzpah that took us some time to grow into. . . . (I'm just saying.)

Case in point:

Just about every week, I find myself in a water cooler chat with a colleague about something an intern, student or resident said that was so . . . .uhhh. . ."no-he-or-she-di'in't!". . . that it leads to more discussion. All from off day "requests" to emails about being excused early for flights to texts about getting out of teaching sessions to you name it . . .all approached with such nonchalant audacity that it, literally, blows the minds of faculty. Our water cooler conversations are almost always punctuated by an emphatic,

"I wish I WOULD have even THOUGHT to say something like that to my chief/attending/program director/senior resident! No way, no how!! I would have been torn a new you-know-what!"

::five way faculty fist bump::

The verdict: Times have changed. Learners are much more comfortable making suggestions to us that never occur to them as outlandish. I can honestly say, I have heard them all. I have been a senior resident, a chief resident, an attending, and now a residency program director--and with every year, the ante gets upped with boldness that makes me (and my colleagues all over the country) say, "Awwww, hell naww!"

Now don't get it twisted--everyone knows how much I love me some interns, residents and especially medical students. . . .so for this reason, out of sho' nuff love and nothing else, I cannot allow this to go on any further. So. . . just for all of you-- my beloved learners, here is a guide to what NOT to say to your attending, program director, chief resident or adviser, no matter how extraordinarily cool and approachable they seem.

Yes, it is 2010, but no, assuming that we do not have a life (or feelings for that matter) is NOT cool. So this is an intervention of sorts. And lucky you, I'll be as concrete as possible by providing a few examples . . . . . balancing it all with some viable alternatives. Yeah. . . . this is a love-filled intervention indeed.

Let's jump right in, shall we?

***

Examples of "No-he-di'in't/No-she-di'in't" Correspondence:

What you said over an email (three days before the start of the rotation):


Dear Attending,

Hope you are well! I am looking forward to working with you next month on the wards. I am emailing you because I made a schedule request with the chief residents to be on this schedule so I wouldn't be on call over the three day Weekend. I have plans to go to Vegas for my best friend's bachelorette party, and was hoping to fly out early (around 4pm) and get that Saturday and Sunday off. I already spoke to the senior resident who said she's fine if you are. Touching base with you to make sure it's okay.

Thanks in advance!

Dr. Pria Sumptive

Let's try a better approach, shall we. . . . .(One month or more before the rotation starts)

Dear Attending,

My name is Ina Turner, and I will be rotating with you on Team X in September. I am contacting you to discuss a scheduling issue that I have considered for next month. My best friend and roommate from college and medical school is getting married this year. I have been fortunate enough to be asked to be her honor attendant, and already scheduled vacation to be able to attend her New England nuptials. She is also an intern, and she, as well as several of our mutual friends, have coordinated their schedules to meet out of town for a bachelorette celebration in her honor over the Labor Day weekend. I recognize that so early in the month and in my internship that this could be a hardship. I am respectfully asking for the consideration of being afforded two consecutive off days for my best friend's celebratory weekend. While our team is not admitting, I realize that this could potentially inconvenience others on our team, especially you. I have not yet purchased a flight, and would absolutely understand if this were not possible. The specific days are Saturday, the 4th and Sunday, the 5th. I will be post overnight call on Friday the 3rd. Thank you for your consideration and I am very much looking forward to working with you next month.

Very best,

Intern

That's what I'm talking about! Okay, maybe it was a bit longwinded, but it was definitely unassuming and respectful. (You would SO get that weekend off if I received this correspondence! Again, I'm just sayin'.)

***

What you said. . . .

Text message:

Hope u don't mind but gonna pass on our special session this afternoon. Long day for me in the hosp and feel a migraine comin on. BTW feel pretty up to snuff on stuff ur covering. Hit me back if an issue --thnx. Holla--

Noah Di-int, Medical Student

What about this approach instead. . . . . .

Good afternoon, Dr. Attending. I am concerned that I am feeling a migraine coming on. Do you have a moment to call me to discuss our session this afternoon? Thank you, Noah D. Medical Student

Isn't that better? Was that so hard? (Even if I say no and make you come anyway, at least you won't get the hairy eyeball when you arrive.) By the way, note that not everyone is cool with the text message. If you do get the green light to text, I might suggest avoiding "text speak:" e.g.

"OMG Dr. M! LOL ur blog is awsme! TTYL!"

***

What you emailed the Chief Residents or Program Directors. . . .

Dear Program Director/Chief Resident,

I was counting my shifts on the ER schedule and noticed that I have one more shift than everyone else. John got ten shifts and Jasmine got ten shifts, too. I have 11 which is not fair. I also noticed that I did not get a full weekend off, which doesn't allow me to make any kind of plans such as travel, etc. While I do not celebrate Christmas, I am kind of annoyed that I got picked as the one to work during that time. I just don't think this is fair and hoped you could step in. Also, is it normal to have two calls that fall one on a Friday and another on a Saturday? Jasmine did get one Sunday, but she didn't get a Friday which does not seem fair. You can tell me if I'm being irrational.

Wine E. Resident

Try this approach. . . .an invitation to talk--not an email about this (which almost always sounds whiny.)

Dear Chief/Program Director,

Would you be available to meet with me soon? I wanted to discuss a couple of concerns about my schedule with you and hoped I could get on your schedule. I am at Grady all this month, and am available whenever you are open. Thank you for your consideration.

Resident, Pager 12345

So simple, yet so effective. Ya dig?

****

See? It isn't really that hard.

Here are the take home points:

• Assume nothing.
• Our time away from work is just as valuable to us as yours is to you.
• If you just started your residency or medical school, factor that into your requests.
  
• Sometimes you just can't go.
  
• Do NOT buy plane tickets before speaking with the attending. Don't do it.
  
• When you have a request, make it formally and make it EARLY.
• You are NOT entitled to your request unless there are special circumstances.
• Why? Because this is what you signed up for.
  
• THINK about what you are sending and to WHOM you are sending it.
• We work harder than you realize on teaching students and residents. It is hurtful when that is not considered.
  
• Just because our response doesn't sound like we want to go off on you, doesn't mean that we aren't going off about what you said/did/assumed/requested in our heads/to our spouses/at the water cooler.
• Formality gets you further than overly familiar assumptions.
• You signed up for this.
• To quote my friend and fellow Grady doctor, Ira Schwartz, M.D.--"This ain't college."
• 
  

On a serious note, medicine involves sacrifice. Be smart before you speak and ask yourself if what you want is actually realistic and appropriate for the timing, rotation, and even your profession. If the answer is no, let it go. Know that we work hard to strictly adhere to duty hours rules, off day regulations and all measures designed to protect you from burn-out, stress, and not having a life during training like we experienced. Despite those measures, medical school and residency involve work. They also involve missing out on a couple of things sometimes. It is our job to help you achieve work/life balance through it all--but you must know that the word "work" is a part of the equation, too.

Capisce?

***

For the record, I am 100% serious, and hope that the medical students and residents out there who run across this take it as such. Feel free to save a med student and forward this to a friend. . . .

~ With nothing but love and hopes for your very best future, Dr. M ***

**Students, Interns and Residents that I saved today:

You can thank me with Target giftcards, red wine, or key lime pie. :)

***

Grady Seinfeld Moment on a Tuesday: Rusty Butterknives

**written with patient's permission, but details, names, etc. changed. . . . you know what it is.


TODAY at Grady:
______________
Nurse comes up to me and says, "My new patient down there is off the chain! He doesn't trust anybody!"

"What room is that?" She gestured over her shoulder to the room behind her. "Wait," I laughed, "That's my patient. I was just going to see him."

"Whew, well good luck, Dr. Manning. He's kicked about three folks out already, including the consultants. He is completely off the chain. Not mentally ill. . .just. . .off the chain." She shook her head and continued to finish charting.

I knew something good was about to go down.

I enter the patient's room all cheery. His TV is off, he is looking out of the window. Appears totally harmless and 100% on the chain.

"Hey there, Mr. Jackson! I'm Dr. Manning. I just wanted to stop by and--"

"You a intern! Get away from me! I don't want to hear NUTHIN' you got to say!"

Voice is like Wolfman Jack. Almost cartoon like. Wonderfully grouchy without warning. One of my favorite kinds of patients--cantankerous for no reason.

"No, sir. I'm not an intern. I'm actually--"

"You actually ain't been a doctor no more than three years tops. Jest open your mouth and say you been a doctor longer than three damn years so I can tell you you a damn lie!"

Retract that first statement. Definitely is off the chain.

"Uuuhhhhhh. . .well actually--"

"You a lie if you say you been a doctor longer than five minutes."

Feeling myself getting amused. "Dang. Why do I have to be 'a lie?' Seriously, Mr. Jackson, I'm actually the attending doctor and---"

"What do that mean? You the what? How I'm 'posed to know what the hell that is?"

"The attending is, umm, the senior doctor on the team."

Gives me the hairiest eyeball ever. "YOU? You the senior doctor? Jesus Lawd-ta-day I'm in trouble! How long you been a doctor?"

"For fourteen years, sir."

"You a lie! You ain't been no doctor no fourteen years! Hell naw!"

"I'm serious, sir." Failing miserably at hiding my smirk.

"I'm serious, too. You lyin'."

(Is it wrong that I was vain enough to take this as an age compliment? Please blame that on me being just two weeks shy of the big 4-0. . .I'll take what I can get.. . .but I digress . . . .)

"I'm not lying, sir. I'm not an intern or a --"

"That's some bull!"

::Sigh:: "Okay, seriously, sir--" cuts me off again.

"You know what, doc?"

Rub my neck and inhale deeply to will myself some patience. "What's that?"

"I bet you be down in that operatin' room cuttin' on somebody with a rusty butterknife!" (now mumbling under his breath) "A doctor for fourteen years, my ass. . .what you think I look like? boo-boo the fool?"

(me under my breath) "Umm, actually I'm not a surgeon." Wait, why am I even entertaining this? This is going on way too long. I try to inconspicuously make a quick scan at the clock.

Busted!

"Oh, you gots to go or somethin'? You out of time and need to go read a medical book so you can learn what the hell you doin'?"

"Wow. You're in rare form, Mr. Jackson." (It's official now--yes, he is very much off the chain. )

"You damn right I'm in rare form. This how you take care of yo' self. I always ask who folks is. I always ask what's up, shoooooot."

"That's actually a good thing, sir. As a matter of fact--"

Interrupts me again, but for some reason, now speaking in this really calm, voice. "Do you know what Jesus said, doc?"

Loaded question. I mean, like Jesus said a whole bunch of stuff, now didn't he? Usually when my Grady patients bring up Jesus they haven't just called me a lie repeatedly, so this was a first. I thought about all of the red writing in the New Testament and hoped he didn't plan to recite it all to me. I'd already been called a lie twice and an assassin, so decided to erase my amused smirk and oblige him with the simplest answer I could muster. Here we go. . . .

"What did He say, sir?"

"He said, 'You ain't got nothin' 'cause you don't ask for nothin'!' Tha's what He said!"

(Sorry, y'all, I couldn't resist.) "Uuhhhh, okay. . . ummm, like, which bible translation is that from?"

What did I say that for?

(back to off the chain yelling again, throws covers off his lap) "Oh SEE, you thank you FUNNY! You thank you GOT JOKES, huh?! Look here, doctor," --wait, he made air quotes, when he said doctor!--"I asked the Lord to help me know what's goin' on in here and you got jokes. See some folks don't even be trying to know what's goin' on. All these interns and they rusty butterknives coming at 'em--but me? I knows 'cause I ask."

"Sir, seriously, our doctors are amazing and very much qualified. The student doctors are, too. This is one of the best medical schools in the country, and we are proud to be here for you. And I assure you, there are no rusty butter knives around here."

He ignored all of that.

"You know what else Jesus said?"

"Ummm, I'm not sure, but I do know what He did."

"What's that?"

"He wept." A chuckle snorted out as I thought of the shortest verse in the whole bible. (Jesus wept. ~John 11:35)

"Oh see, now you really thank you funny! Trying to get cute."

(can't help it, now can't conceal my amusement at all.) "No for real, Mr. Jackson, I think He wept when He heard that you wanted to leave without completing your work up. And when He heard you insulting me earlier."

"Naw. . .He wept when He saw you coming at Him with a rusty butter knife and a brand new stepascope."

Both of us look at each other for a beat, and then burst out laughing so hard that the patient in the next bed laughed out loud, too. It was really a moment. We both cracked up until tears rolled down our cheeks.

Finally, I took his hand and this time, he let me. I felt his pulse and examined him. I even used my stepascope.

"You gonna let me work on getting you better, Mr. Jackson?"

"Yeah. I guess, so. But you better have me better in three, four days. Then I'm leavin'."

"Dang, Mr. J! What if I need more time than that?"

"Then you need to get fired, 'cause if you been a doctor fourteen damn years and it take you that long to get somebody better, you need to find another line of work." His eyes twinkled mischievously.

I offered him my biggest smile and looked back up at the clock. "I'd better get to work then."



***

I love--do you hear me?-- LOVE working at Grady. :)

Reflection on a Tuesday: Black and White

pt. names, details, etc. changed . . . you know the deal, man
a "black and white" cookie, Brooklyn style

_____________

"Sir, I know that was a lot of information. I just want to be sure I did a good job explaining to you, okay? Can you tell me why we said you were in the hospital?"

"Sure, Miss Mannings. Y'all said I got pneumonia in my chest but then when you looked closer you saw a spot, too. Since I smoke, you want to be sure that it ain't more than just pneumonia and not something like a. . .cancer?" He smoothed the covers out over his long legs and rested his pecan colored arms on top of the blanket. His cheeks were covered with a smattering of moles and skin tags, likely from years of working out in the sun doing construction.

I drew in a deep breath. "Yes, sir. That's correct." I felt the need to make it sound less daunting. "But we aren't saying that what we saw looks exactly like cancer either, sir. I admit it was concerning." Great, now I'm backpedaling. "I mean, it's just that it's important to be sure, sir. That's why we are having you get that test by the pulmonologists or lung doctors. Do you remember what I said that test was?"

"You talking 'bout that test with the camera down your throat?"

I wished that his graphic description wasn't spot on, but it was. His wise sixty-something year old eyes didn't look the least bit fazed by the idea of something sounding so noxious as a "camera down your throat." Again, I wanted to dampen it a bit. "Umm, well. . .you know they do make you drowsy for the test and then carefully put this very small tube with a camera on it through your mouth to get to your windpipes. That's how they are able to see inside your lungs."

"Right. Down your throat, and then they stuff it in your breathing tube. That man said it's like a tree that they look down all the branches of. As I thank of it, I'm guessin' sometimes it ain't nothin' but leaves when they look, but sometimes it's something else growing on the tree that ain't 'posed to be there. Like cancer." He let out a nervous laugh.

I couldn't argue with his accurate description, and was admittedly quite impressed with the metaphor he used. The timing couldn't have been better--we had just had a lecture earlier that week on "Health Literacy" that was really driving home the importance of making certain that our patients understand what we are doing and saying. The lecture emphasized the need to say things in black and white, instead of chartreuse and celadon. Even though the plan itself wasn't that great for him, this was an example of a successful "teach back." The team listened quietly and seemed to acknowledge this as a teachable moment.

I turned toward the team and said, "It sounds like Mr. Chambers has an excellent understanding of what's going on with him!" I looked over at the patient and smiled. He returned the expression, but shortly after furrowed his brow and turned his lips to the side. Something was puzzling him. "Wait, Mr. Chambers--did I speak too soon?"

He chuckled and said, "Naw, I know what y'all doin' today. This my body. . .shoooot. . . you know I'm gon' know when it come to my body!" But then he narrowed his eyes and looked like his wheels were turning again. It was confusing.

So then I remembered the other health literacy guru tip that often gets forgotten. Instead of asking folks "do you have any questions," you pose the question the way I asked Mr. Chambers:

"Sir, what questions do you have for us?" I gestured to the medical student, Ania, who'd been carefully doting over him throughout his hospitalization.

I felt pretty sure that he would have at least one, especially with that puzzled expression he kept offering me. I was right.

"I don't have no questions for her," he spoke firmly while pointing directly at Ania the way Zachary points at Isaiah when I ask who did something, "but I DO have questions for you, Miss Manning."

I felt relieved that he was willing to ask what was obviously becoming a pressing question. "Okay, Mr. Chambers, go right ahead."

He stared at me for a few seconds like he was deciding on a Final Jeopardy answer, and finally broke the silence by saying, "Miss Manning, are you black or white?"

I raised my eyebrows in surprise and looked over at Ania who immediately blushed, initiating a domino effect with the rest of my all fair-skinned team.

Now here's the deal: I am not offended by this question, nor are my feathers ruffled in the least when it is asked--but the thing is that I usually see it coming. (See this post about Grady and the race to determine my race.) Furthermore, it always amuses me since when I look in the mirror, I see a black woman looking me squarely in the eye, albeit one with freckles.

"Am I black or white?" I repeated for clarity.

"Yeah. What are you?" He looked at me as if this were not a not-so-PC way of asking such a thing. For him, obviously it wasn't.

"What do you think I am?" My team couldn't figure out if I was embarrassed, amused or what. They shifted on their feet, somewhere between uncomfortable and intrigued.

He studied me for a few minutes and then said, "I was thankin' you was black, but I don't know. You sound black. If you ain't black, you sho' sound black."

My team was now crimson. I laughed out loud to lighten things up and let the team know that I was okay. "Okay, so here's the deal, Mr. Chambers. . .my mama, she's black and my daddy, he's black. Does that help?"

Instead of thinking this was cute, he sat there thinking as if I was Rumplestiltskin asking him to guess my name. He tapped his finger on his lip and sighed. Still in Final Jeopardy mode. I knew I'd need to let him off the hook.

"Mr. Chambers, I'm actually black." He nodded his head like that's what he was going to say and smiled. "Was there a reason you wanted to know this?"

"Honestly, doc? I was just curious. I just be wantin' to know stuff like that and I get real curious, and you seem cool so I figured I could ask."

"Does it make a difference to you? I mean, are you okay with a black doctor and . . .the rest of our doctors?" I nodded my head to Polish Ania, Taiwanese Emily, and the rest of our team of varied European descent.

"Oh yeaaaaaah," he laughed in the most unassuming way ever. "Don't matter what y'all is. I just be wantin' to know little stuff like that, tha's all. All y'all cool wit' me. Black, white, blue, whatever!"

Nice.


So that was that. My patient who might have a primary lung cancer--a possibility that he fully understood--did have a question indeed. It wasn't the kind of question I expected but that's what happens when you ask, "What questions do you have for me?" -- and that's what happens when you have the distinct pleasure of working at a place like Grady Hospital.

Same Reflections, Slightly Different Address: www.gradydoctor.com

"Reflections of a Grady Doctor" can now be reached at:

www.gradydoctor.com

Much easier to remember, and best of all, this reduces the chances of this blog disappearing into thin cyber-air (which I am told can happen--gasp!) If you forget, don't worry--you'll still be redirected to gradydoctor.com when you use the "blogspot" address. I am told that securing a domain is a good idea as you get more readers. This could be completely false and simply a ploy to get folks to buy a ten dollar domain. Anyways, while I am no Perez Hilton, I am up from my 5 followers that I had this time last year!

Please update this in your browser. . . and really--thank you for continuing to read. . . . . .and, ahem, comment (*except for my friend/fellow Grady doctor, Lesley M. who has been given carte blanche for verbal Grady hallway comments since she is one of my very first and most loyal readers. She does faithfully provide me verbal comments, which I sho' nuff appreciate.)

But for the rest of youse, it's kind of fun to know that me (and my mom and Lesley) aren't the only ones reading . . . . . thanks for the feedback and the reactions. :)

Reflection on a Sunday before going to Grady: Kitchen Floors

Today when I woke up, I didn't really want to do anything other than nothing. I am by no stretch of the word the type who needs to stay in bed all morning, but Lord knows I love me a good ol' extended, early morning snuggle fest on the couch with my two stinky little boys. But I had to work, so that was out of the question. Bummer.

Decided I would sneak in just a few moments of snuggles anyway, and then enjoy a cup of coffee before getting ready to head to Grady. I initially planned to return emails and read a review article on Rocky Mountain Spotted Fever over coffee, but instead sat at the kitchen table savoring this image:

::sigh::

Watching Isaiah and Zachary sprawled out on the couch watching "The Electric Company" just put me in a trance. I thought about how blessed they are. . .I am. . . . and how it simply isn't a promise for it to be that way. A life that consists of a warm house with a Mommy and a Daddy who love not only you but each other and who openly role model to you how to give and accept love. Toys to play with, yogurt to ask for, cable channels to choose from, shoes to turn down in the place of other pairs, and just. . . .contentment. The contentment you see in this picture.

This month, I discharged two patients straight to the street. Not because our amazing social worker hadn't arranged either a personal care home or a ride to a shelter, but because the patients were of sound decision making capacity and preferred the street to a shelter. One guy told me, "I'm okay with the street. It's all I know." All you know? Damn.

Another patient started crying this month when I told her she was HIV negative. She admitted that she stopped "turning tricks" only a few months ago, and was afraid that she wasn't worthy of a second chance.

"Why prostitution?" I asked, knowing the answer.

"For crack." Wished I was wrong.

"So do you still use . . . the crack?"

"Nope! It's been 4 months, that's why I'm so happy I'm negative." Face lights up. . .so much that she started crying some more. I was so happy to hear that she was off crack that I almost broke her hand from squeezing it so hard.

"I'm so proud of you! That's awesome!"

"Yeah. . . . I'm just so ashamed for making so many bad choices, you know? My son. . .he gone. He don't even know me, doctor."

I thought about one of my favorite quotes from Oprah Winfrey that's taped to my office door. I held her hand even tighter and at the risk of sounding corny, I shared it with her. "There is this quote I like from Oprah Winfrey. . .she was talking to this woman on her show once who had made a terrible mistake. . .actually had been drinking and driving and hurt some people. . .and she was so ashamed and sorry, you know? She was crying and everybody was judging her. Oprah told her, 'We are not our mistakes, we are our possibilities.' I love that idea. Today I am saying the same to you."

She cried some more, and (y'all know me) as soon as I got out of her room, I did, too. Turns out this young woman was raised by her alcohol addicted mom and (still) crack-addicted father who fancied her early-blooming body at 9. Would get high and then have his way with her. She learned to hate herself early and you know what happened next. Enter crack cocaine. "Out there bad" as she described it. . . "just trying to make herself disappear." Pray my boys never want to just disappear. Never. But how can you blame her?

Remembered something I heard a patient say once about crack:

"It's the loneliest, most hateful drug you can use. With marijuana, you pass a joint. With heroin ("hair-ahn") you tie each other off together and shoot each other up. With lines, you take turns. But crack? You want to do it all by yourself 'cause you want it all to yourself. You don't want to see nobody you love 'cause they gon' tell you to quit. You don't care about nobody, not even yourself. You just want to get high. Then by the time you ready to quit, your people don't want to f--- with you no more 'cause they scared of you. So you get lonely and depressed. No choice then but to go get high."

A lot of my patients have lived some hard lives. Instead of being sprawled out on a couch in a sun drenched living room, at Isaiah and Zachy's ages some of them were sitting on roach-infested kitchen floors where there was way too mature music playing in the background. Instead of somebody cooking up thick sliced bacon, the crackling sound of a water, baking soda and powder cocaine concoction became the other music that was too mature for their ears but equally mundane. A sound as every day to them as toast popping up in a toaster or coffee brewing in a coffee maker.

I look across the kitchen table and see my boys lying there like little angels wrapped in a cherished cocoon of PBS Kids channel nurture. . . . . at that moment, my heart is as glad as it is sad. I try hard to see the silver lining for my patients; imagining the one gentleman that said he only knows street life under the warmest, driest bridge in Atlanta. I silently pray that my beautiful little sister who had just stopped prostituting her body for crack cocaine is somewhere sitting on a God-fearing auntie's porch getting her hair braided for a job interview on Monday. And I pray for mercy and for grace. For them. For me.

I sip my coffee and take in the image across the room. . . .struggling with the aspects of God's will that simultaneously tear at my heart and cause it to overflow with happiness.

Reflections of a Full-Time Working Mother slash Clinician-Educator: "A Change is Gonna Come"

Things that make life easier for me, Volume 1.

Apple stuff. . .the boom boom and the pow.

Okay, so today I was off--YAY!--and in the grocery store grabbing a few items (or "staples" as my mom says) for the house. As I pushed my (kid-free!) shopping cart, I found myself thinking about how many great inventions there have been over the last two decades that have made my overscheduled, overstretched, and all-around wacky life much easier. Boy, have the last twenty years been good to us technologically!

At this very moment, I have no idea how my mom and all the moms before her managed without microwave pancakes or phones that email and text. It's good to be an adult in the midst of all of this. Getting in trouble and getting "busted" take on a whole new meaning with all this technology. One time, Isaiah's pre-school teacher sent a multimedia video text of him throwing a temper tantrum. Just pulled out her phone and just like that, he was totally busted. Talk about the Y2K version of a "note home from school!"

Anyways, I can't say enough how much some of these inventions that now seem every day have changed my life. I gave God a shoutout right there in Publix Supermarket for evolving life to this point, just in the nick of time for me to take the stage as a mother/wife/physician/teacher/grown woman.

At the risk of seeming like a horrible mother and homemaker, I will list a few things that I periodically look at and think, "What a great idea, man!" Would totally be interested to hear a few of yours. . . . .

1. Text messaging and the QWERTY keypad.

First of all, I personally think this was invented for husbands, or at least mine. 99% of the sweet nothings I hear are not whispered in my ear at all but are in the form quick text messages (fortunately without too many gag-inducing emoticons.) "Love You." "You make me so happy." "Thank you for all you do." It's like my stoic Ranger Harry turns into a big ol' soft teddy bear at the hands of a Blackberry. I firmly believe that the text message revolution is one of the best things that has ever happened to our marriage. Not the best, my friends. . . but like. . definitely one of them. I'm just saying.

2. Microwave pancakes and fully cooked microwave bacon.

OMG. Praying that the microwave is not a poison box because it sho' nuff gets used in my house. Whoever came up with the six second bacon deserves a fist bump, for real--it's crazy.

For the record, I don't even EAT bacon. But kids? Kids like bacon and pancakes. (If you are a health nut and a strict vegan, I assure you that behind your back, even your little angels would inhale some bacon, too.) In case you missed it, I barely have time to eat a bowl of cereal, let alone whip up pancakes with a side of bacon. This invention completely rocks. Completely.

3. ON DEMAND Cable Television and DVR/TiVo.

You pick the show you want to watch, and watch it when you want. Genius. You can record what you like, and then fall asleep in front of it at your own discretion and schedule. Double genius. Thanks to this, I will never miss the Oprah show again. (Although I am starting a one year mourning process as her final season starts this September. . . . )

4. Wi Fi and changes in the internet.

Good heavens. What on earth did we do before "hot spots?" Do you remember waiting for your phone modem to connect? The only thing I miss about that is the AOL man saying, "Welcome! You've got mail!" Other than that, it's a beautiful thing.

Furthermore, this has revolutionized medical education. I cannot believe that when I was a med student we had no email, email addresses or Power Point. No Power Point? Crazy, I know!

5. Multi-media text messaging and cameras that take photos.

Keeps you and the kids in touch with the grandparents, and is a great way to amuse yourself during boring meetings. (Just kidding. . .errr. . .I always pay attention in meetings.)

6. Navigation systems.

The best, man.

7. The complete comeback of Apple products.

The iPod started it all, and then they were on a roll. Am in love with all from my MacBook Pro, to my iMac, to, of course, the iPhone . . . . .gasp. . . and my newest baby, the iPad! I even named her. "Patty." (Lame I know, but she's such a great friend.) I'm a self-proclaimed Apple snob--totally.

Case in point:

Colleague-friend: "I don't know what's wrong with this stupid computer!"

Me: "I do. It's not an Apple."

Colleague-friend: "Snob."

Me: "At least I ain't two-thousand-and-late like you." (Yes, I may have actually said this. . .)

8. Jog Strollers (Double and Single.)

Looovveee them. The only thing better than the single jog stroller is the "double wide."

9. One cup coffee makers.

Feeling warm and fuzzy just thinking of it. . . .

10. Digital photography.

You can take a trillion and delete all the ones that make your face look fat or where you forgot to hold in your tummy.

11. Amazon kindle and the whole book download revolution.

Love. It.

12. On-line Bill Pay.

The bomb. Haven't bought a stamp in like, ten years.

13. Cosmetics for people of color.

God bless you, MAC cosmetics.


14. iTunes.

Sigh. Yesterday on rounds my almost 80 year old patient told me she loves Nat King Cole and Sam Cooke, and wished she could find her old albums. I downloaded her two favorite songs right there on the spot, at her bedside, and played them for her on my iPhone. "Unforgettable" and "A Change is Gonna Come." You tell me what is doper than that? Better than any medication I could have ordered on her chart or any consult.

Her smile and surprise were absolutely the best things I have seen all month. The best. Hands down.

15. Google.

Heavens to mergatroid! What did we do without you, Google? How were we able to determine impostors from real folks while simultaneously finding the nearest "Yoforia" yogurt spot?



I'll stop at 15, but am sure more will come to mind. . . . . .aww shoot! Forgot to say on-line shopping and on-line pizza ordering . . . . .oh and can't forget on-line airport check-in. . . . .oh man, and YouTube. . . . . . .


__________________________________________________
Click here to hear Sam Cooke singing "A Change is Gonna Come" the song I played for my patient. . . . I wish you could have been there to see it. . . . .eyes closed, shaking her head from side to side, and snapping her long, leathery fingers. . . . sigh. . .makes me wanna cry just thinking of how happy hearing those songs made her. :)

"MY Sam Cooke" as Mrs. T called him

Unfair Speculations.

thanks e. and b for getting me reflecting on this. . . . .

"When you talk to her
Talk to her

Like you'd want somebody to

Talk to your mama. . .

Don't get smart with her

Have a heart to heart

With her just like you

Would with your daughter. . .

Everything you do or say
You got to live with every day

'Cause she's somebody's baby

She's somebody's sister

She's somebody's mama."

from India Airie's "Talk to Her"

__________________________________________________________

The other day I had just finished a teaching session with my small group of second-year medical students and was preparing to leave the School of Medicine. On the way out, I stopped to briefly chat with Elle and Bridget--a couple of other M-2 students from a different group. They were working on a project and wanted a little bit of "attending level" input. While I can't say that my "attending level" input is equivalent to that of say. . .a professor emeritus, it was nice to have been asked.

Anyways, the business part of the conversation somehow winded its way to a discussion of life experiences. Specifically, we talked about how life's little speed bumps shape the kind of doctor you become. For example . . . . . how patient or how gentle or how fierce an advocate or how fill-in-the-blank you are with your patients. . . .maybe it all has (much) more to do with the hand life dealt you before you started medical school than anything us "attending level" folks could ever impart in a classroom or on a ward.

Just maybe.

And so we got-to talking and I got-to thinking. I found myself telling them this story about an experience I had with a doctor when I was 16 (and a half) years old. A pretty unpleasant experience, actually.

Funny. . . .I hadn't thought about it in so many years. . .in fact, I'm not sure I ever properly processed my feelings about it. I discovered for sure that it was unprocessed when this wave of emotion tried to sneak up on me when I was sharing the story with them. . . . . whoa. . . .loose ends. Yikes. (Fortunately, this time I managed to fake wistfulness instead of just full on crying--thank you, years of drama lessons.)

Okay. . . . so here's my crack at really reflecting on this. Note that this is an attempt to process something that I now realize has a lot to do with who I am as a physician and how I treat my patients to this very day. To try not to assume anything about them. To try hard not "size them up" based upon what they look like or where they live--especially working at a place like Grady. This story factors into all that for sure. . . . and just maybe has a teensy-bit to do with me becoming a Grady doctor.

Just maybe.

me as a 16 year old Junior circa 1987
(rockin' the asymmetric mullet look--you know you love it)

The Story. . . .

When I was 16 (and a half) I was pretty much consumed with competitive cheerleading. Period. I ate, drank and slept herkies, toe-touches, and pyramid dismounts and spent every free moment I had choreographing a routine for the next half-time show or pep-rally. It was varsity cheer, all the time--and when I wasn't with the varsity squad, I was coaching freshman and JV cheer. I lived my life to an eight-count rhythm--jotting down potential formations in a spiral notebook with hearts and rainbows on the cover and considering every new song I heard on the radio fair game for a dance sequence.

Okay. . .so like many 16 (and a half) year old girls, I had a boyfriend back then, too. This really cute boy that my older sister Deanna had introduced me to during my freshman year (her boyfriend's younger brother, actually.) He was appropriately studious, yet regarded by most people as an A-list "cool kid." He became my "boyfriend" over the summer preceding my sophomore year and definitely upped my cool stock bigtime. Cute-boy rode next to me on the travel bus during basketball away games and walked me home from school and shared chili-fries and honey buns with me during second lunch. Cute-boy was pretty special and was the first to make my heart go pitter-patter.

I think, just maybe, I even loved Cute-boy (that is, for what I knew love to be back then. . . .)

Anyways, at 16 (and a half), I was a junior and Cute-boy was a senior. Our relationship involved lots of kissing and okay--sometimes really heated make-out sessions--but for some reason, it never got to much else. We're all adults here, so I'll just say it: We weren't having sex. Not even close, actually.

The interesting thing about it was that it was mutual. . . . just this unspoken understanding that we weren't going there. And it made me feel special since Cute-boy was one that could have easily secured a girlfriend that was more. . .errr. . .giving (which he eventually did. . . ha ha . .) but during this time, when I was 16 (and a half), he only had eyes for me. Me and only me.

As for the abstinence thing, I can't say that it was because of a fire and brimstone upbringing or some intense commitment to not disappoint my parents. (Sorry, mom/dad.) I'm not sure it was ever that deep. It just was sort of . . .not really on my radar. . .like. . .having a boyfriend was really great and Lord knows I was infatuated with Cute-boy, but my other relationship--cheering--sat squarely on the front seat between us like a bratty kid brother. It didn't take extraordinary willpower or anything like that to not "do it." It just sort of wasn't my thing.

I recognize that this was probably a bit unusual back then, and even now--especially in my neighborhood. In my Inglewood, California hometown and high school, teen pregnancy was viral. It was nothing for someone to be plucked out of the cheerleading roster due to being. . .well due. Case in point: my two senior cheer captains during freshman year both had children over the age of 1. Umm, yeah.

Several of my peers were sexually active back then, but there were definitely a good number of us that weren't. And some how, contrary to what you'd guess, the seasoned girls never picked on us novice girls. . . .we all just sort of happily coexisted. Stretching on the grassy field before cheerleading practice. . . .some making loose references to "doing it" and others discussing the elements of the perfect back handspring.

One week after "two-a-day" practices leading up to our big Six Flags competition, I noticed a discomfort. Itching, to be exact. I dealt with it for a few days until it became rather unbearable. I did what a lot of kids do--told my mom.

"Mom, I'm itching. . .ummm. . .you know. . .itching."

"Do you see anything in your undies?"

"Eeeww, Mom!"

"Well, do you?"

"Kinda. Like whitish? I don't know, Mom!"

"Okay, I'll take you to the doctor," she replied. "It's probably from all that sweating you do with cheering."

I shrugged a teenage shrug and thanked my mom for being so responsive.

A day or so later, my mom and I rode to this doctors' office that I'd never been in before. As we walked into the building, I thought I'd get the lowdown.

"What doctor is this?" I asked Mom.

"The doctor for women," she said matter-of-factly. "Now that you're a young woman, you don't need to see the pediatrician any more."

"Uuuuhhh, okay."

And so I see this doctor. This forty or fifty something year old male gynecologist who promptly kicked my mom out of the room and got down to business. Steely blue eyes and wavy brown hair. A light on a band around his head.

"Where's high school?"

"Morningside High. . . in Inglewood."

Inner city, check.

"Do you have a boyfriend?"

(blushing) "Yes, I do."

Having sex, check.

"Pretty serious one?"

"Uuuuhh, I guess."

Definitely having sex, check, check, check.

"Okay. Put on this gown. Undress from the waist down. Underwear, everything."

"Uuuhhh, okay." Mom? Where'd you go? Underwear, too? Never had to do that before. Not too sure about this. Now feeling a little nervous about the doctor for women.

Undress. Try to put on paper gown. Hmmm. Open to front or to back? I don't know. Guess I'll put it on like a jacket. Open to front. Hope it's right.

No door knock, just walked right in, this time with a nurse. "Hi, I'm back. You ready?"

"Uuuuh, I think so."

"Okay, lay on your back, put your feet right here, and scooch your bottom all the way down here." Holds his hand at the end of the table. Stick my heels in these foot holders. This is odd.

::Scooch::

"No, more than that."

::Scooch::

Nurse speaks up. "Sweetie, scooch til' you feel like you are going to fall off."

::Scooch. Scooch. Scooch::

Doctor speaks again,"That's good. Okay, honey, I'm gonna need you to open your legs more than this." Pushes on my knees to make the point.

"Ummm, okay."

"No, hon. More than that."

Nurse: "Like a little froggy, sweetie. Open your legs like a little froggy, okay?"

Like a froggy?

Doctor sighs. "Come on, honey. Really going to need you relax these legs." Pulls on my knees a bit. Not sure how I feel about it. "Just. . .relax. . . these are just my hands. . just looking, hon. . .relax." Touches me. Feel gloves touching me. Trying to relax. Oh yeah, maybe tell him what Mommy said?

"My mom said it could be yeast since I cheer and run and stuff."

"We'll see." Don't think I like how he said "we'll" or "see." Like he thinks what I said was dumb or not important.

"Oh, okay. Just thought I would tell you."

"Look, honey, I really need you to open your legs more." Pushes both heels of his gloved hands on my inner thighs. Don't like this and don't get this. At all. Want to relax, but this is not relaxing.

Nurse: "Like a froggy, remember?"

"Like when you have sex," he added.

Like when I have what? I wasn't sure what to say. Felt embarrassed that maybe I should have been having sex? Like 16 (and a half) is kind of old to not be, right? But don't know what to say in response. Tell him I'm not? No, stay quiet. Wait 'til it is over. Will be over very fast. I don't think I like this woman doctor.

"You are going to feel something cool. That's this, the speculum." Raises his hand up in the air from the stool he is sitting on. I see something just above my knee for a fleeting moment. Some kind of metal thing that looks like a giant, steel duck bill. Have never seen anything like it in my life. What is he going to do with that? Not sure. But okay. Gonna try to relax.

"Okay. . . .pressure. . .pressure. . .just relax. .now I'm just going to open the--"

::::SCREEEEEEEAM!!!!::::

I bear down hard and sit up in sheer terror and surprise. Metal duck bill flies out, hits the tile floor.

Ting-o-ling-o-ling!

Crying. Wanting to go home. Willing to live life with yeast or what did Mommy say it was? Don't care. Can't be life threatening. Want to leave. Shaking. Please. Just no cold pressure duck bill. Ever. Again.

Or "honey." Or "sweetie."

"Okay, listen, honey. We can't tell what's going on unless you--"

Nurse with arm on my shoulder: "Sweetie. . .have you ever had, um, an examination like this?"

"Nooooo-ho-ho-hooooo." Sobbing. Terrified. Shaking. Wiping face hard with hands. Kind of embarrassed. Didn't expect this. Wanting my mommy. Wanting my daddy. Wanting to go home. Never come back. Ever.

Nurse and doctor look at each other like, What's going on?

Doctor breaks silence. "Honey, when was the last time you and your boyfriend had sex?"

Tired of him calling me honey. Is that supposed to make me more comfortable? "Huh?" Still sobbing. Now confused. Shaking, too. This is a mistake. I am not a woman. I do not belong with the woman doctor. Where is my mommy? Go get her. Please. This is all a terrible mistake.

Doctor becomes a super-sleuth. "Sex. When was the last time you did it with your boyfriend?" Holds up hand and makes an 'o'. . .then gestures with gloved finger going in hole.

What is he talking about? I didn't say I did that. Why does he think that about me? When he looked and touched with those gloves was there something about me that made him think that?

"Umm, I haven't had sex with my boyfriend." Still shaking. Still kind of crying. Wanting this to end. Don't know when or how they got this idea. Okay, we kissed a lot, and okay it was french-kissing but I'm pretty sure that doesn't count. Does it?

Doctor getting annoyed. Nurse looking worried. Doctor going to get to the bottom of all this: "Okay, hon, then what about the last time you had sex with anyone?"

"Sir, I never had sex with nobody before."

Nurse gasps behind me, but I hear her. Feel the gasp, too, even though I don't see it. Nurse looks at Doctor. They mumble something to each other about being able to get something from metal duck bill to make a slide. They mumble a few more things in my direction but all I hear is "honey" and "sweetie" but not "sorry."

Pull the curtain back. We will be right back. You can get dressed. Here--tissue to wipe your bottom.

Crying while I get dressed. Crying and shaking and confused about this place for women. Am I a woman? I don't think so. Never want to see this kind of doctor again. Ever. Never. Used the tissue--a little blood. Oww. Get dressed. Want my mommy. Want to leave. Never come back. Ever. Next time, the pediatrician, okay? Never want to come here. Ever again.

Knock, knock but open the door at the same time before I can say, "Come in." Still buttoning my pants. Don't know where to throw away the blood tissue. Ball it up in my hand. Doctor starts talking. Headband with headlamp pushed back on his wavy brown hair like a hair accessory now. But light is still on. Weird.

"Your mom was right. Definitely looks like yeast. Be careful to change quickly out of sweaty clothes after cheer practice or running. That's why this happens. Cotton underwear can help keep you dry, too. Okay hon?"

"Okay."

"You'll take this medicine for seven days. You take this thing here, put this cream in it and just push it right inside your vagina, okay? Every night for seven days."

Inside? My what? "Okay."

"The nurse will check you on out. Your mom will be waiting for you in the waiting room."

"Okay."

Nurse--this time a different one--comes in and tells me the same thing. Any questions? Yeah, have many but too scared to say them out loud. Might act like what I said was dumb. Or unimportant. Really want to know if I can get something that I don't have to put inside my vagina because I am scared of inside. But that's okay--won't talk because I just want to leave. Never come back. Never. Ever. Ever. Get me to my mommy. Need my daddy. Leave this place for women because I am still a girl. A girl, do you hear me?

Nurse: "Sweetie, would you like some condoms and foam?" New nurse, same pet name.

"Excuse me?"

"Condoms and foam. Would you like some?"

"Uuhhhh. . .no, ma'am."

"If you do, they are in this bag, okay?" Sits a brown bag on the counter and pats it. Almost looked like she wanted to wink. Like it would be our little secret. But I didn't need a secret with her. Too young and too scared to know about reactions like, "This is bullshit!" or "How dare you assume anything about me!" Too young to know how to advocate for myself. Or fight like a woman. Because I am a girl. A girl, do you hear me?

Staring at New Nurse and saying nothing. Just thinking and shaking and wanting to leave that room with the duck bill and the foot stands. Get to my mommy, not my mom. Want to tell her and them I am not a woman. I am a girl still. See my mommy in the waiting room reading "Redbook." Gives me a big smile. Like maybe it was a rite of passage? Not sure. Want to tell her what happened. About how they thought I was a woman but I am a girl.

Mom puts arm around my shoulder after we pass through the exit. "How'd it go?"

Don't know what to say. Don't know how to be. Not sure how to feel. So say nothing.

Out of the building. California sunshine on my face. Warm and nurturing. Like my mommy. And like my daddy. Nobody saying "hon" or "honey" or "froggy" or "sweetie." No duck bill or pressure or scooching. Glad it's over. Just want it to stay over. . . .

Mommy got in the car and looked over at me as I connected the seatbelt. Her eyes were twinkling. "Well? How'd it go?"

Can feel the wheels turning under the car. Building disappearing behind us getting smaller and smaller. Decide I want this to disappear, too. . . . . hoping the memory will get smaller and smaller.


"How was it? Uh . . .fine, Mom. It was fine."


***

Now playing on my mental iPod. . . . 



________________________________
Talk to her. . . . just like you would with your daughter. Take a minute to listen to this if you can.