How to Destroy a Mother-Daughter Play Group

There were so serene, so peaceful. Three mothers and six daughters all sat chatting on their trampoline at our local trampoline park. It definitely looked like a planned outing. Maybe they did it every week. They seemed to have that particular spot staked out.

As I had one eye on him, I had another eye on what would be the end of their tranquil morning outing. My son was struggling to get his shoes off, eyes transfixed on the rows of trampolines in front of him. I'm sure that playgroup looked at those trampolines each week and saw a lovely, relaxing morning. Unfortunately for them, my son saw his chance at toddler ninja warrior glory.

I probably should have warned them but I figured my son had already given them a decent warning shot across their bow. Immediately after getting our shoes off, my son ran up to one of the little girls to see hello. The timing could not have been better as the speaker system came to life, and music began booming through the whole place. Little buddy immediately began breaking it down, complete with yelling for the little girl to join in. Needless to say, she didn't join in but merely stared at him with mouth open.

Undeterred, little man moved on to the trampoline stretch occupied by the aforementioned playgroup and began to unleash the hounds on them. As he bounced and shrieked, I had an incredibly hard time holding in my laughter. The dainty girls tried to continue to sit quietly, but that's really difficult to do when a screaming banshee is right next to you.

Ultimately, I had a parenting choice to make. I could quiet my son and ask him to restrain himself at this trampoline park that we had paid good money to enter, or I could have some fun. I chose fun.

I hopped onto the adjoining trampoline and began jumping as high as I could go (not that high really, but toddlers can't tell that just yet). Another little boy came over and joined in. My son screamed his approval.

As the whole place began to shake, the exodus occurred. The mothers and daughters began running for their lives in much the same way that ants run from flowing water. While giving me the dirtiest looks possible, they beat a hasty retreat for the other side of the trampoline park, away from the raucous and unrefined males.

My little man and I had a marvelous time. We jumped and performed semi-dangerous tricks for about an hour. Those little girls didn't get with one hundred yards of us, and that's OK. We had a decision to make and we made it. When entering a trampoline park, you can either jump or you can sit. We chose to jump, and we took no prisoners.

I Work for VA

I've received a lot of weird looks when I've uttered that sentence the past month or so. Colleagues look at me as if I've lost my mind. I've had a few ask me,"Is that a good thing?" Several people outright asked me if I was nuts when I informed them that I was transitioning to VA a few months ago.

I was inundated with horror stories about being treated poorly and delivering substandard care. I was told that no doctor works for VA unless you can't get a job anywhere else. In short, I was told that I was committing career suicide.

Let's be clear. There surely have been some unfortunate things that have happened at VA. No one is trying to hide from the hard work that must be done to give Veterans the care they deserve. That wasn't a mystery when I decided to work for VA, and it isn't a mystery now.

Now, allow me to be equally clear when I say that I have never been more proud to walk into work every day than I am now. Every day, my team and I get the opportunity to care for heroes. We hear stories from the beaches of Normandy to the mountains of Afghanistan. We give back to those that have given so much.

I say my team and I for a reason. Delivering health care at VA is unlike anywhere else. While many health systems are still exploring the concept of team based care, the VA has already embraced it. As the physician, I am the leader of the team, not the entire team.

Instead of asking for my patient to get a colonoscopy and praying that it actually happens, my nurse follows that consult all the through to the end, making sure the procedure gets done. When my patient's blood pressure  is out of control, a telehealth nurse will call that patient regularly and track their blood pressure from home. Abnormalities are communicated back to me, and we can make adjustments, while the patient never has to set foot in the clinic.

So, I want to set the record straight. There is good work being done at VA. There is constant improvement happening. Our leader, Secretary McDonald, has brought with him a culture of service, and as one of the many new faces around VA during the past year, we are daily going about the task of bring world class health care to our Veterans. If you are a veteran, I invite you to stop by your local VA clinic to learn about how we can help you. If you are a health care provider, then join us. We don't just care for patients, we care for heroes

Reach Out and Touch Someone

My wife and I differ in our communication styles. Pretty common for a married couple, but I’ve been struck by a thought recently that perhaps my personal communication flaws may be more a generational problem. At the risk of further admitting that my wife is right about a lot of things (love you honey!), I’m willing to put one of my flaws out there. My communication style is lazy. 

What do I mean by this? Well, I grew up with instant messaging, text messaging, and email. It’s a really easy way to communicate and can be very convenient. It’s also very easy for someone to hide behind it. Want to break some bad news or say something that might make people uncomfortable? Send them a text. Don’t have to watch or hear their reaction and the message has been delivered. Want to say you “followed up” on something without really caring whether it happens or not? Send a busy person a two line email that will get buried in their inbox. Mission accomplished! I’ve checked a box off my to-do list without really accomplishing anything.

The more years that go by and the longer I work a real job, I’m much more inclined to “reach out and touch somebody” if there’s something I need to communicate. No, I don’t mean physically lay hands on people, but I do mean either talk in person or call. I’ve found that I can not only confirm that my message has been delivered much better, but whatever task needs to be done actually happens at a much higher frequency when there is a real voice on the other end of the line.

Case in point, I needed my student loan servicer to fill out a form for me. They have a lovely chat function on their website where you can get “instant help.” I hopped on and chatted with customer service rep, who assured me this could be done without an issue. I faxed in my form and waited…and waited. Nothing happened. I got on again. They said they never received the form and to fax it again. I did…with no response.

This happened one more time before I finally called in. After explaining that I was not a happy camper, I was transferred to a “resolution specialist” who physically sat by the fax machine, received my form, signed it, and sent it back. The whole process took twenty minutes. I had been waiting for two weeks.

I know my wife is smiling at this point while reading this. She has been saying for years that this culture of sending email for everything and actually talking to no one slowed everyone down. Well honey, here are those words that you love to hear…you were right. As a culture, we tend to rely too much on technology assisted multi-tasking. We check boxes but don’t really accomplish anything. You want to get something substantive accomplished. Talk to someone. You might even enjoy it.

The Potty, Part 1

We are starting to introduce the concept of the potty in our household. We're in no rush fortunately. By virtue of little man's birth date, he will be nearly 4 when he enters 3K, giving us a lot of extra time. We've decided to take it slow because he's just beginning to show interest.

I should clarify what I mean when I say "show interest." Currently, "showing interest" entails having all of your stuffed animal friends sit on the toddler potty, flushing, and all dancing together to the music. This experienced is capped off with an exclamation of "Yay! You went to the potty!" 

We'll take what we can get. Little man notoriously starts slow with new activities and then quickly become a daredevil once he gets the hang of it. I did catch him trying to take his diaper off the other day, so maybe that's a good sign. Then again, he's also picked up watercolor painting recently and had his eye on a section of wall in the bathroom...

Communion Meditation 5/31/15

In our church, people rotate giving a short meditation before communion each week. People typically do this for one month at a time and then rotate. It is my turn this month, and these are my thoughts I shared today in our communion meditation. 

I've started gardening here recently. Nothing too complicated. Just four pots with one each labeled tomato, zucchini, cucumber, and squash. You can ask anyone that knows me; this was pretty shocking. I'm not the most handy individual. In fact, I often have no idea what I'm doing when it comes to any kind of home project or yard work. Tim Herlihy can vouch for me back there. He drove by and saw my yard after winter and just shook his head. I could hear him saying,"What is that boy doing?"

Believe it or not, I have managed to get the beginnings of some vegetable plants in my back yard. You see, despite my lack of green thumb or ability, growing vegetables isn't complicated. The ingredient list is short. Seeds, soil, pots, water, fertilizer, sunshine. That's it. Make sure you plant around the right time of year and keep the water and fertilizer coming. You'll have a fighting chance if you do that.

Watching these plants grow every day has been refreshing for me. Unlike us, these plants do not seek answers for their future or what God's will for them might be. The cucumber plant is a cucumber plant. That's what it aims to be. It doesn't try to become a tomato or zucchini. With all of it's needs supplies, the future of these plants is secure. They will become what they're supposed to be. Questioning that would be ludicrous.

The truth is that our questions about Gods will for our lives often sound just as ridiculous as if my cucumber plant were asking them. What job should I work? Should I live in this neighborhood or that one? Its just like my plants asking should I put my roots on this side or that side? Should I catch that raindrop or this one? These are really trivial questions in the grand scheme, and all of them come from an innate need for security and answers despite the fact that God has already provided for our every need no matter what neighborhood we live in.

So lets stop making it complicated. Lets stop being cucumbers trying to figure out if we should be tomatoes. Lets just be God's children and let that be enough.

Limits

Those of you that have read my previous communion meditation have heard me talk about limits. The stark reality of critical illness causes these limits to be displayed most prominently. There is no denying your limits when the patient worsens in front of you and you have no answers. It is undeniable.

The idea that we don't have limits in all other aspects of medicine is pervasive, however, and ridiculous. People are like that, though. We will always deny what we can't do until it becomes immediately obvious that we can't do it. Happens in all other aspects of life. Politics, business, all the same. "Sure, I can get that order done by tomorrow." "Read my lips, no new taxes." We've all heard it. We've all fallen for it, and yet medicine still gets away with it.

There are very practical implications to refusing to acknowledge our shortcomings as a profession. Our stubborness translates into real dollars and cents, real resources wasted in the delusional pursuit of ends that we claim to be able to reach yet lack the tools to reach them. 

End of life is the most obvious case study of this. What do you do if someone is dying but you view death as failure and merely a manifestation of some other lesser physician's previous mistakes? You burn through resources, that's what. You throw the kitchen sink at the "problem." And then? The patient dies. Every time. Without exception. 

It's an oversimplification of course. Some folks are critically ill and will recover wonderfully. We can't perfectly predict who will recover and who won't, but we certainly have a good idea sometimes. More importantly, and more central to what I want to say today, we often know who wants to use those resources and who doesn't.

Informed consent was initiated in the noble pursuit of joint decision making and patient autonomy. Why don't we tell the patient all the possibilities and let them decide? Sounds nice. It's imperfect, though. How do I adequately explain the risks and benefits of a procedure that it took years of school and training to master and understand? Explain that in ten minutes? Forget about it. Its a farce.

No matter how many forms you get patients to sign saying they understand everything and have made the decision all by themselves, physicians will always play a central role in making patients' medical decisions. Sadly, this is where physicians' refusal to acknowledge our limits most hampers, and dare I say harms, our patients. What do you do if a patient is wavering on a procedure that could prolong their life if you believe that death is failure and only happens if you allow it to happen? You push. You cajole. You tell them how they really want the procedure, how it will help them.

Patients will relent usually. They trust their physicians. However, they won't be better for it. Unlike physicians and their God complex, most of the patients that I have cared for do not view death as failure. They view death for what it is. Inevitable. If we are really acting as a medical fiduciary for our patients, then how should this affect our decision making? Should we make decisions based on our personal views of death or our patients?

If we accept that our patients views of death and disease are more important than our own, then this begins to have every day implications. Do you use low value tests and procedures that often result in much lower quality of life with minute quantity of life gain? Probably not. Out the window goes "routine" blood tests every three months, a lot of heart caths and CT scans. Costs come down. Patients receive care more in line with what we know works the best.

From an individual physician standpoint, the trade off comes in time. It will take serious time to explain to patients why they don't need a test. Much more time than to simply order the tests. As in all situations, inaction must be explained more than action, even when inaction is the correct action. That means a lot more of our day sitting in exam rooms simply talking to patients, learning their views and preferences. We must know the whole person if we are to consider the whole person in our decision making.

That should be no problem, though. Most physicians indicate that they got into medicine for the purpose of knowing and helping people. So spending large amounts of time talking to patients and not ordering tests that can make you more money should be second nature, right? Let's hope so...

Ants

Watching a two year old figure out the world can be pretty entertaining sometimes. There are hard times, of course, but some of the situations are downright hilarious. Take my little man's relationship with ants, for instance. The weather wasn't heating up for very long before those familiar ant hills appeared in our back yard. Little buddy was fascinated.

I could see the toddlers wheels turning. "How did this pile of dirt get here? I didn't put that there. This must be a trick." The first time he saw an ant crawl out of there, he immediately backed up. "What is this mystical, miniature being? There is no way that one of those could have moved all this dirt." The first time he saw me kick an ant pile and all the ants scatter? Pure chaos. "There's a million of them! We're being invaded!" He took off for safety immediately, otherwise known as Mama.

You more senior parents out there already know what huge mistake that was. Little man immediately took to using whatever objects were available to destory every ant hill he encountered. This was especially difficult becaus we were trying to impart to him how ants would hurt him. You could see the indecision gripping him. He would run up to the ant pile with ball in hand, ready to do battle. He would stop about two feet away and look back at me as if asking,"Are we going to war today or running for our lives?" I felt for him. No toddler warrior can work in this kind of environment.

We have managed to strike a balance in our relationship with ants now. We have adopted the same relationship with them that we use for strangers. That is, you are nice but wary. Thus, walking across our back yard with him is punctuated by stopping multiple times so he can wave at each ant hill and yell at the top of his lungs,"Hey, ants!" He will then stoop down to inspect each pile before moving on to the next one. 

As icing on the cake, he has even figured out that each hill is the ants' home. Unfortunately, this has presented him with an entirely new set of problems. We are now at the stage where finding an ant outside of an ant hill is the equivalant of seeing a missing child when an amber alert is going on. He starts screaming,"Oh no! Ant, ant, ant!" I've even overheard him sternly telling a solitary ant marching across our driveway that it needed to go home immediately. Fortunately, I haven't witnessed any rescue attempts as of yet. We all know how well that would go. Toddler warrior would return and unleash Hiroshima on the ant population of greater Berkeley County. Our family just doesn't roll like that.