Be Brave today and everyday!

B7A04BC0-8AA7-4808-AEF4-1968CF88C1C3Fear was holding me back for so many years with my health… fear of failure, fear of injury, fear of other people’s opinions, fear that I just didn’t possess the strength within me to change. When I stopped being afraid I was able to take action. To be vulnerable, open, and honest with myself and everyone around me. To acknowledge that I am far from perfect, that there was a huge portion of my life making me miserable. Once I was able to admit that, I was able to transform.
It has been scary. To put myself out there, where anyone can see if I fall down or fail- it’s terrifying. But without taking that risk I would still be that women who was living an only partially fulfilled life- always wondering “what if”. When I look at my body now I still see a lot of flaws, but I am through being hung up on them. My body is getting stronger and healthier everyday, and I choose to celebrate that progress, even if it doesn’t look perfect!
So do the thing that terrifies you the most. Buy a bikini!!! (And if you feel particularly nutty then post a picture of yourself in it on the internet!) Go skydiving or scuba diving or mountain climbing! Give a public presentation to a huge crowd! Speak up at work and get involved! Travel to a different country! Take a new job!
Whatever it is, do it. Don’t be the person always saying “what if?”
Be Brave!!!

How to Go Grocery Shopping

B153DF51-B13F-4E87-9289-BF98274C731ESo grocery shopping is actually very easy, it’s all about geography! Shop on the perimeter, not in the middle! I buy 80% of my groceries from the produce section. Fresh food is good-for-you food! I am vegetarian, so obviously I load up on veggies. Fruits, too. And then I get my dairy, also on the perimeter- eggs, milk, and cheese (always cheese I love it!). When I venture into the middle of the store it is to get whole grains- farrow, wheat berries, whole grain bread or beans and legumes- chickpeas, black or pinto beans or nuts- mostly almonds but peanuts, pecans, and walnuts as well. Always read your labels, too! So many processed foods have added hidden sugar and calories in them! I like to get bean based chips or chia seed crackers, which have a higher protein content. I do not eat enough protein, so I’m always looking at ways to sneak in some extra servings. If you simply follow the perimeter rule your nutrition will instantly improve!

A word about body acceptance and positivity


I’d like to say a word about weight and body acceptance.  I am so very happy to see that recently there has been so much focus on body positivity and self-love. When I was a teenager I was ridiculed for being a mere size 10-12 and it was really horrible. Nowadays there is so much more variety of shapes and sizes in women all over the media, and I think that is a wonderful thing.  Even when I was my most obese, I could still actually buy fashionable clothes that were comfortable and fit me. I am grateful that those options were available to me.
However, the more obese people there are at younger ages, the more we will have health problems when we are older.  I know many people who say “I am fat (or obese) but I am healthy, I have no other medical problems”.  Yes, when you are young and obese (overweight is BMI up to 30, obese is BMI over 30, morbid obesity BMI over 40) it is less likely to have other medical problems. But the longer you remain obese, the more medical problems will develop.
What I worry about- in myself and all of the children, teens, and millennials out there whose weights are on the rise- is that this generation will be the ones stricken with early onset heart disease, diabetes, high cholesterol, stroke, etc.  In fact, I already see many patients with just those problems who are in their early 20s and 30s or even younger- coming in to the hospital having heart attacks and strokes much earlier than they should be.  My point is: never feel as if you have to hide your body or be ashamed of it- your weight is only one component of your overall being- but still continue to work to be healthier each day.  Obesity is a chronic progressive disease, and treating it as such can help reduce the stigma surrounding weight. The bottom line is it not healthy to be obese, and we can all do a better job taking care of ourselves!

How the Chronic Pain Crisis Feeds the Opiate Crisis

What is it like living in pain? Those of us that have ever experienced unremitting pain for months or years know that it is enveloping and all consuming. I myself struggled with intractable pain for several difficult years, and I am fortunate because my pain finally got better- what if your pain never did?
That is a horrible reality millions of people are living in right now. The chronic pain population in this country is astronomical. Our offices, urgent cares, ERs, and hospitals are being overrun with patients whose pain is out of control.  These patients want a solution to their pain, an end it. But in many cases we do not have a cure, we cannot make the pain go away. So we shift the discussion to managing the pain, and coping with it.
The problem is, many are not coping- they are turning to pain management and chronic narcotic therapy or illegal drugs for the pain numbing effects of opiates. When legal pain management options have failed them, some patients turn to illegally buying pills or using intravenous drugs. In the process many will lose their jobs, their houses, their families, and even their lives. Does this happen to every patient with chronic pain? No, but we are seeing this pattern more and more.
How do we reverse the climate in America which presumes physicians can provide instant or complete pain relief? How do we as providers set the expectation that we very likely cannot rid our patients of pain, but slowly try and manage and reduce it? And do it all without using opiates?
Well, it will take a seismic shift in culture. We as a society are so wired to the mentality of “take a pill and make it better” or “we can operate and fix that” that patients demand this when they come to us. To explain to our patients that we don’t have a quick fix is frustrating not just for them, but for us as well. When a patient is in pain, it can seem impossible to convince them to accept as treatment any of the many proven pain management techniques that aren’t a narcotic pill (including physical therapy, exercise, cognitive behavioral therapy, medication for psychiatric comorbidities, tens units, injections, spinal stimulators, acupuncture and massage etc). Historically, writing a prescription is easier and takes less time than having that kind of difficult discussion with a patient.
With the right approach and buy-in from members of the medical community, we can change this country’s outlook on treating chronic pain. It will take a concerted effort from each of us prescribers to stop utilizing opiates. If we don’t, the opiate addiction plague is going to become even more wide-spread and thousands more will die. One of the barriers to this culture change is that many patients have no faith in non-narcotic pain management. This despite study after study showing that opiate treatment for chronic pain has no benefits long term
with regards to morbidity or mortality. It does have significant risk of harm. That fact is now well known to physicians but not well known or understood by the public. We need to alter the conversation with our patients, and take opiates off the table as a routine treatment option. We can then redirect our efforts to optimizing the modalities that have been shown to have a positive effect on chronic pain. To that end, we need to open more clinics where multidisciplinary non-narcotic treatments can be offered to patients. Here in Ohio, it takes months to get into a pain management specialist, and in the meantime most patients will survive by going to urgent cares and the ER to get short term pain pill prescriptions. What these patients really need is to start PT, behavioral therapy, nutrition and exercise plans- so how can we make that the new expectation?
Since I started medical school I have seen the battle with chronic pain and opioids worsen ever year. We have created a healthcare system in which many patients have been treated for pain with long-term narcotic pain medications, and it is extremely difficult to walk back from this mindset. The consequences have been devastating to see and are continuing to accumulate. Reform is ongoing with more and more regulations over who can prescribe what narcotics and for how long. These regulations will definitely help to decrease use, but we as a medical community have to keep working everyday stop the cycle of opiate prescribing.  The more boundaries we set, and the harder we make it to access opiates the less prevalent they will be in our society and our medical practices.


Is fat bias affecting your medical care?


We are all guilty of having biases. Some of them we know about, and even proudly flaunt. Some of them have been ingrained in us so deeply we do not even know they exist. Weight is an issue that brings out strong biases, and multiple studies have demonstrated a high level of bias from physicians against overweight and obese patients. Obese patients are often treated rudely and are not given the same level of medical care as non-obese patients. One study (Huizinga MM, et al. J Gen Intern Med. 2009) even showed that as a patient’s weight increases, physician respect for the patient decreases. Think about that- the more overweight you are, the less value you are perceived to have as a person. As both a physician and someone who has until recently been obese for my entire adult life, I can personally attest to the prejudices which exist within our field.
I myself, even as a doctor, have been fat-shamed by other physicians. (Note: by fat-shamed I do not just mean told to lose weight. Discussing weight loss is part of our jobs! I mean that my treatment as a patient was of poorer quality than if I had been of normal weight). There is so much stigma and negativity around obesity, it leads many care providers to blame every patient complaint on their weight. Let me be very clear: yes, many many complaints and health issues are actually due to obesity and can be improved or cured with weight loss. And absolutely every chance we get we should counsel our patients on weight loss.
But our job as physicians is to help guide patients down the right path with support and encouragement. To individualize recommendations that will help our patients succeed. To give them resources and ideas. To be compassionate. Not to just judge patients at face value and dismiss them. Empathy and understanding go a long way. Even if you find it hard to relate to someone struggling with obesity, treating every patient with respect and dignity is the bare minimum requirement!
In my time during medical school, residency, and now as an attending I have been privy to many discussions among providers about obese patients. A prevailing attitude through the years has been that obese patients “did this to themselves.” Meaning, the patient is at fault for being fat and therefore at fault for having whatever complications and co-morbidities befall them. This is the same attitude I see towards drug abusers and alcoholics- that their medical problems are somehow less important because they are “self inflicted”. Just as many factors contribute to drug and alcohol addiction, so is true of obesity. If we just focus on providing empathetic, non-judgmental care we will have better relationships with our patients and their health outcomes will improve. So let’s all put our biases to the side and focus on providing the best care possible to each and every patient.

How safe are we as healthcare providers?

Being a healthcare provider has always come with personal risk. We care for all patients, which includes patients agitated due to psychiatric issues, dementia, acute medical illness, alcohol or drug intoxication, or simply anger. Patients can be extremely volatile and lash out unexpectedly, causing physical injury to their doctor, nurse, or other provider. Besides the physical risk, patients can be emotionally and verbally abusive as well- both types of violence take their toll. Workplace violence is on the rise and OSHA reports indicate that only 70% of violent encounters are ever reported upwards to a supervisor. The NEJM published a review article last year on workplace violence calling it a “problem that had been tolerated and largely ignored”. Healthcare has the highest incidence of workplace violence outside of law enforcement.
Recently the dangers of patients unhappy and dissatisfied with their care, particularly as it pertains to obtaining controlled substances, have been making the news. This danger has been increasingly apparent since we as providers have been scaling back on prescriptions of controlled substances, but reports of abusive opioid seeking patients were readily available years ago ( A most extreme example recently occurred in Indiana where a patient’s husband shot and killed her doctor for not giving her an opiate prescription (,amp.html). This was the first time the patient had seen this physician, and this single patient encounter led to his death. Several years ago, another irate patient in Kentucky murdered his doctor for not prescribing him opiates- he was sentenced to 40 years in prison ( Both these physicians were killed for practicing good medicine, and this is a heartbreaking, frightening reality.
As we as a medical community continue to grapple with the risk of workplace violence, is there anything that we as individual providers can help to prevent protect ourselves? I would offer the following:
1. Be clear immediately and up front with the patient what his or her expectations should be. Many PCP offices have instituted policies where they never prescribe controlled substances, or at least never on the first visit. Knowing this information as soon as possible, ideally before the appointment, can help to diffuse the tension or lead the patient to seek care elsewhere.
2. In the hospital setting, there are on call police and security teams and special codes to raise the alert for violent patients and trigger a response team- know what your policies are! In the office where this response team is usually not possible, have a clear safety plan in place with your staff and a pre-planned method to alert them to your situation.
3. Be alert to the risk of violence before you enter the room. Has the patient been violent in the past? Do they have mental health, addiction, or chronic pain issues that place them at a higher risk for violent behavior? Consider tagging patients’ medical records to alert the staff of the risk for violence. If you know that risk is present, do not go into the patient’s room unattended.
4. Either in the hospital or office setting, when a patient starts to become agitated and violent, do the following: a. speak softly and do not raise your voice b. listen actively and maintain positive nonverbal communication with eye contact and nodding c. acknowledge that you can see the patient is frustrated and upset d. reassure the patient you are listening to his or her concerns e. let the patient talk without interrupting them f. ask what you can do to help resolve the issue
5. If you sense the situation is going to escalate, and cannot be resolved, move slowly toward the exit. Keep as much physical distance between yourself and the patient as possible. Alert the surrounding staff and call the police as soon as is feasible.
6. Report any violent encounter according to your hospital or clinic protocol.
7. Talk to your administrators about workplace violence policies that are in place or under development at your hospital or practice.
Violence in our workplace is an ongoing issue. We can each help by reporting all violent incidents as they occur, and having firm policies and procedures in place.

The agony of being a patient


We have all heard that old saying “doctors make the worst patients”. It always uncomfortable and humbling to give up control and be a patient. I’ve been a patient in various capacities throughout my medical training. With my primary care doctor, who knows to reign in my gut reaction for always thinking the worse-case zebra diagnosis scenario. With several trips to the ER for such human ailments as severe dehydration causing fainting or intractable migraine… where the ER staff was always polite, efficient, and preserved my dignity. And in Mexico where I spoke little of the language and spent 12 hours in a hyperbaric chamber with a lovely man named Juan watching Miss Congeniality during a frightful episode of the bends.
My biggest trial as a patient began one innocent night playing indoor soccer. I recently had been getting back into shape so I thought our residency soccer team would be a great way to elevate my fitness level. Alas, a mere 5 minutes into the game I collided with the ball at the same time as a player on the other team. In a split second I was on the ground. I heard a loud “pop” and felt a sudden excruciating pain in my right knee. Instantly, I knew I had torn my ACL, maybe done even more damage. There was a constant string of profanities coming from my mouth as my husband and friends helped me off the floor. I sat in shock icing my knee for the rest of the game. Stunned, I hobbled to the car and made a call to get in the next day with a sports medicine doctor I knew and trusted.
In my sports medicine doctor’s office I sat numbly waiting for a few minutes. He couldn’t do all the components of a standard knee exam due to the significant swelling and my pain. He tried to reassure me that perhaps I only tore my MCL, but we needed the MRI to know. Of course the MRI showed the more difficult to treat scenario of a torn ACL, torn lateral meniscus, and tibial plateau fracture. Quickly resigned to my new reality, I went to see an orthopedic surgeon. This was a physician I had spent time rotating with during my medical school. I didn’t know him well personally, but he had a good reputation with other doctors I knew. At my appointment he reiterated the diagnoses and then we discussed surgical options. His recommendation was for a patellar tendon graft from my “good leg” to repair my torn ACL. The surgery would be scheduled in a month due to the severe edema still present from my initial insult.
At the time of my injury, I was in my second year of residency training in family medicine. Instantly I was back in the clinic seeing patients on crutches until my surgery date. The day of surgery, I was fairly nonplussed and told my husband to go home and take care of our dogs and tidy up the house while I was in the OR. The last thing I remember was transferring from the gurney to the freezing operating table. I was mortified that the doctors and staff would see my underwear more than anything. I woke up in the PACU with my husband by my side. The meds were still in full effect from the surgery, so the pain was tolerable. A physical therapist got me set up with my ice machine and quad exercises to start at home and I was wheeled to our car. Somehow we got me home and into the house before I collapsed onto the guest bed and slept till the next day.
The first 2-3 days after surgery were excruciating. I awoke on the guest bed only to find I couldn’t stand up. I tried and tried, each time screaming out in pain. Finally, with my husband’s help I propelled myself upwards so I could go pee and move to the couch. As I had surgery on both my legs, due to the graft harvest site, I no longer had a “good leg” and was struggling to maneuver with each step. I spent those first few days on the couch with my paralyzed beagle-basset Beau faithfully by my side for company. Spinning in a Percocet induced haze, I forced myself to get up and move and do my exercises.
After a week, I was ready to start my rehab in earnest. I was getting around better and the pain had manageably subsided. I only needed the Percocet before therapy sessions and at bedtime, preferring ibuprofen instead. I was excited to get going with my physical therapy, to get back to normal. Everything went well for the first month, and I was diligent and worked hard. Then one day after my therapy session, I noticed my knee felt very stiff. The next morning I couldn’t straighten my knee all the way, it’s like something was blocking its path.
Frustrated, I went back to my orthopedic surgeon. He examined me and said that I just needed to keep working through it and I would regain my range of motion. So that’s what I did. For weeks, with no improvement, I worked and worked to get better. After some time my surgeon decided that we needed to force my leg into full extension or I would lose my range of motion permanently and always have a limp. This process involved what is called extension casting. Basically, this form of treatment involved a resident or my surgeon and nurse standing above me and pushing down as hard as they could in my leg until it straightened while another resident put a cast on the straight leg. I cannot fully summon the memories of those casting sessions. I remember only screaming and swearing at the doctors and nurses and thinking that I may pass out from the pain. It felt like a form of medieval torture, not treatment.

The next few months were a step and repeat of extension casts. I diligently followed all instructions and hoped each time the cast came off my knee would be improved. It wasn’t. It came to the point where I would start to panic before appointments with my surgeon. At this time, I had missed months of my residency training and I was falling further and further behind my peers. I worried everyday that I may be fired for being unable to complete my job. The pain continued to be nearly intolerable, but I pushed through it because I had to.
Worse than the physical pain was the emotional toil this process took. I couldn’t walk. I couldn’t walk without pain, without a limp, without crutches. Each time I would see my surgeon I‘d become more desperate. I’d beg him to consider other options, mainly arthroscopy to find out what was blocking my extension from being normal. These discussions were harder and more painful than every single cast I was put into. Each time I saw my surgeon I would start off by having a rational discussion as a doctor who also happens to be a patient. As the weeks wore on, my ability to regulate myself and be clinical about my situation lessened drastically. After a few months, I barely wanted to speak to my surgeon. When I did speak I inevitably would start to cry and lose control of my composure. I was a doctor myself, yet my surgeon was not taking my opinions seriously and was not listening to me. I felt like I was a broken record and that no matter what I said, he wouldn’t hear me.
Eventually, I had to return to my residency training. I was no better than I had been that day my knee seized up on me months before. I wore one of my extensions casts all day at work that had been cut into halves so I could remove it when needed. Part of my job as a resident on call was to respond to and run any “code blue”. I adapted to this by calling the nurse on my way across the hospital while I wheeled myself there in a wheelchair. It was very difficult to complete the physical demands of medicine with a significant physical disability. At the end of each day I was physically and emotionally exhausted. I stopped even thinking about not being and pain or walking regularly and tried to focus on just getting by. The last time I saw my orthopedic surgeon, he asked how I was doing. I was an empty shell of myself, depressed and in despair. I barely looked him in the eye and resigned myself to the forgone conclusion of his advice: “there’s nothing else we can do now. Keep doing your therapy. Your quad strength isn’t good enough. If you get stronger you should improve your extension and mobility.” I felt so insignificant, like nothing I could say or do would ever get through to him. He wasn’t listening. He didn’t see me. He talked “at” me and not to me. Most hurtfully, he placed the blame on me for my failure to get better. I wasn’t doing a good enough job with my therapy and exercises, therefore if I didn’t improve I had no one to blame but myself.
At this point it had been nearly a year since my original injury. I had not improved and remained in constant pain with a terrible limp and needed a crutch to get around. I made the decision to go to another surgeon, in a different group, for a second opinion. I sought the recommendations of another local doctor and one at Ohio State University. At my initial visit with the local doctor he listened to me, heard my concerns, and then recommended continued conservative therapy for now. We agreed on a steroid injection into my knee to see if that improved my condition. We discussed at length that another surgery may only make things even worse, but it may be the only option if the injection didn’t help. The surgeon at OSU had agreed with this plan, so we proceeded to carry it out.
The injection did help for awhile, it improved my pain and I could walk slightly better without a crutch. It’s effects lasted for about 2 months before I regressed. At that time I met back with my new surgeon and we agreed to proceed to arthroscopy. There were no guarantees made, and I understood that if no mechanical cause was found I would be left with no recourse but to hope the physical therapy and time would eventually help. I had communicated with my initial surgeon on and off via email, and with my next surgery approaching, this is the last email I wrote to him:

Dr. X,
I stopped coming in to see you when I felt the doctor/patient relationship wasn’t working any longer.  Honestly I was very frustrated, as you know, and I couldn’t hear another platitude without a contingency plan for what we would do if my knee did not improve. I felt like there was an absolute communication breakdown between us. In late summer I finally was able to wean off my crutch but still had persistent pain and limp. My physical therapist discharged me as she said there was nothing else she could do to help me, we had done it all. I saw several other physicians for their opinions and continue to see Dr. K now.  I had a steroid shot which was a helpful band aid for awhile allowing me to do my job during some busy months, but it has now worn off and I am back to limping constantly and being in pain. As such, I regrettably am going to have a scope done in the near future. I do not know why my knee is the way it is, hopefully there will be an answer in the surgery, but I am not a fool to pin my hopes to it. Thankfully I am in a residency program that supports me as I would have long ago been fired if I were a resident in many other specialties, including orthopedics. I look forward to putting this behind me so I can graduate and get a job as an attending.

In the end, my knee arthroscopy showed a “Cyclops lesion,” a small piece of scar tissue preventing my knee from extending fully. Dr. K removed the scar tissue and I went back into physical therapy. It took time, but with persistence I was able to regain nearly all the range of motion in my knee. I stopped limping and put away my crutch for good. I went on to graduate from my residency training and am a happy and successful Hospitalist physician now.
My experiences with injury, surgery, and rehabilitation changed me. I had firsthand knowledge of how it felt to be repeatedly ignored and brushed off by my doctor. I had put my trust into this man, and he had repaid me by belittling me and painting me as the quintessential weak and histrionic woman. It took me years to recover emotionally from what happened. I lived in constant fear of hurting myself again and being unable to walk. I restricted my activities to only safe and low impact exercises to protect myself.
More than that, it changed how I saw and treated my own patients. I do not pretend to be able to help or fix all of my patients. Many conditions are chronic and debilitating, and I do my best to help my patients manage them. What I can do differently is listen to my patients. Truly hear there concerns, fears, frustrations and acknowledge them. Even if I cannot fix them, I do not brush away their complaints, and I try to give them hope. Hope is a factor I was sorely lacking while I attempted to get better. I essentially gave in to my injury and pain and was resigned to it. It was not until several years later that I regained my hope. I finally stopped living in fear and started to just live. I learned to run and jump and dance again. I stopped letting my past injury hold me back, and kept pushing my physical limits. As I write this I am training to run my first half-marathon, a remarkable feat I could never have dreamed even a year ago. The difference from then to now? Hope.
As physicians, we can lose sight of the power we hold over our patients. Our recommendations and decisions can determine the course of someone’s life. When we stop hearing our patients, we lose the ability to connect with them and give them hope. Without hope there is no chance to overcome the obstacles we face in life. I will carry these experiences with me, and I am grateful they have shaped me into the physician I am today.


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