Aaaaaaaahhhhhhh

Ok let me just say, I really want this hiring process to end already.

My work goals for the week include: get grant into shape for submission next Tuesday.  That's it!  I feel like I will be able to accomplish that even with being on call tomorrow and in the OR again on Thursday.

But my life goals are to hire a morning nanny (interviewing someone tonight and another person on Wednesday), and an au pair to start in December.

I am having trouble connecting with morning nannies, so I am incredibly grateful to have a couple of backup plans in place.  I think we will be ok, but it may take some time.

But man, it is raining au pairs.  

We really like one woman for an extension year, and she likes us.  Unfortunately she told me today that she wants to basically find our family, except in California.  I want to say, listen, there is NOBODY like us.  We are weird.  We think you would fit in great with our neighborhood and our family.  JUST MATCH WITH US DAMMIT!  

But, I did not.  Instead I said I wanted to make sure that she was sure she wanted to work with us, and if she needs time to see if a family as magic as we are, except in California shows up, she should do what she needs to do to make sure she's picking the right family for her.

I did say we were interviewing other people too.  Which is true.

I interviewed another woman today who seemed awesome also, but I'm not so sure she knows what she's getting into.  

We also interview a morning babysitter this evening. 

And we interview another au pair tonight as well.  I need to re-look at her stuff so I can remember which au pair this is since there are two more that we are corresponding with as well.

And I'm 3rd call tomorrow.

I am so tired already!

Please make it stop!

(I do realize this is all a bit redundant from my last post, so apologies for the repetitiveness.)
(I forgot to add that in addition to a new dishwasher, we also need to get our freezer fixed.)
(Oh and also, our tv broke.  Fortunately we don't watch much tv.  But as I was walking around FaceTiming with our prospective au pair today I was like, oh don't mind the puddle on the floor.  That's just our broken freezer!  Oh yeah, we are getting a new TV next week.  Look!  I got a new chair that the dog hasn't peed on yet!  Lol.)

You know, it occurs to me that I’m so very lucky to be in a position to fix each of these issues.  I’m even kinda lucky to have these issues, depending how you look at it.  And I mean that, and not just in some obligatory look how pious I am for acknowledging my privilege kind of way.

Now back to the grant.

ETA: Au pair candidate today asked me to describe my family in three words.  I picked the following:
1) Loud (we I talk a lot)
2) Nerdy (we like books and movies that make us think)
3) We don't like the orange man (in case the NSA is spying on us, though who am I kidding, they probably have an algorithm that identifies this too)

What three words or phrases would you use to describe your family?

Childcare

I can't even tell you how happy I am that I am not in training anymore.  Our latest childcare crisis would have put us completely over the top.  The fact that I have some time to actually find someone who is good (not just available), is so helpful, I just cannot even.

This weekend I think I overdid it in terms of plans though, and I am feeling a bit like I've not done enough.

My work list included:
- Read through my grant and make changes --> it looks like I am going to get through most, but possibly not all of it
- Send cover letter and CV to other place I might want to work next year --> probably not going to happen today, maybe Wednesday?

In addition to that I wanted to:
- Take Dylan to her Saturday activities (swimming, gymnastics, riding) --> I did that, but it did mean that I didn't get much done work-wise yesterday.  Though we did spend a few lovely hours at a suburban Whole Foods killing time and stomping lantern flies before her riding lesson.
- Hire a morning babysitter --> we were going to interview someone today at 11 but had a last minute cancellation due to a food allergy.  Makes me nervous about hiring her, even though she seems super nice.
- Hire an au pair --> yep, we are hiring both.  AP would start in December though, so we need gap coverage.

The childcare thing has me more strung out than I'd like to admit.  But, we have had several promising candidates, at least on paper.  And we found an au pair that we like.  I'm having a follow up conversation with her tomorrow (and interviewing two more potentially AND a morning sitter), so we will see how that goes.  I'm hopeful that it will go well, and we will decide to match.  Then I'm on call Tuesday (home call, so just means I'll go home extra late and be the backup for the backup overnight).  So, at least the beginning of the week looks to be a bit insane. 

I also exercised today a bit.  It didn't feel good, but that's probably because I barely went last week and it is so easy to fall out of the groove.  Still glad I did it though.  I need to resume doing little bits every day.

My husband cleaned the garden.  It looks fantastic.

I bought a new tree peony.  They take forever to make roots and ultimately make flowers, but if we stay here it will be worth it.  I also bought some more tulips and raised flower beds, which we will put screens over to keep the tree rats squirrels from eating the bulbs.

Skyped with the nonni and invited them to visit -- we will finally have a free bedroom for them to sleep in, since we will be au pair less for 2-3 months.  Hopefully they will say yes!

And... that's it!  We were going to buy a new dishwasher (old one conked out last week), but ran out of time.  I'm going to look at my Aim 2 of my grant and then drag my daughter to the park, where she will have a good time in spite of whining and complaining the whole way.

Happy weekend everyone!

Surprise Billing Legislation is Just More Evidence the Insurance Industry has us by the Balls

What it is:
Surprise medical bills happen when you go to an emergency room for care, and your insurance doesn't cover services provided by some of the specialists you see, or some of the services ordered.  So, in order to recoup costs, the hospital bills you after the fact for the un-covered care.  At uninsured patient rates.  Which are astronomical.

This (understandably) makes people really mad.

In anesthesia this happens also.  The most common scenarios that come to mind are:

1. The patient presents to the emergency department and needs surgery.  But the anesthesiology company that provides anesthesia for that hospital isn't contracted with that insurance company, so they refuse to cover the service, which the patient can't exactly refuse because, emergency.  (And let's be honest, it's pretty unfair to ask any patient to weigh the costs and benefits of various medical services period on their own, much less in an emergency situation.)

2. The patient presents to a surgicenter for a non-emergent procedure.  The surgeon's services are covered by the insurance company, but the anesthesiology company services are not.  However, nobody knows this in advance because often surgery schedules come out late in the afternoon the day before the surgery, the surgeon's office doesn't check (they probably don't feel the need to).  Or perhaps the anesthesia group does know about the cases in advance, but verifying that the insurance covers the anesthesia ALSO isn't part of the workflow because historically this has not been an issue.  So the patient gets the surgery and then gets slapped with a surprise medical bill they did not expect from the anesthesia group.

How does this happen?  My understanding is that insurance companies regularly change which anesthesiology companies they contract with, and don't necessarily provide notice about said changes to either surgery groups or anesthesia groups (or at very least, the changes do not trickle down to the physicians making the decisions).   This can also happen when a surgeon starts operating at a new surgicenter.

Legislation preventing surprise medical bills will drive up the costs of emergency care for everyone (except the insurance company).  It will also increase the administrative burden to surgery and anesthesia groups to verify coverage ahead of time, decreasing efficiency and costs.  Depending on the work flow in the anesthesia group, it may be impossible to verify coverage in a timely fashion for some surgeries such as those booked at the last minute and quasi emergencies (like fractures, for instance, that don't need to be fixed immediately, but do need to be fixed soon) causing last minute cancellations and services rendered that will never be reimbursed.  Ultimately, the patient is still going to get screwed, and now in addition, the physicians won't get paid.  Physician overhead will go up even more, verifying and re-verifying insurance coverage, since insurance companies can change what providers and services they cover any time they want.

The only stakeholders that win with this legislation are insurance companies.  Yet, American consumers think that this legislation will benefit them.  Maybe they won't get a surprise bill anymore, but they will still suffer decrements in care in other less visible ways.  Physician practices (but who really cares about rich doctors?) will be hit too.  Some will go out of business.

Bottom Line: It's just another way for insurance companies to avoid paying bills, while deflecting the blame onto doctors. 

Well, and feedback

It has been quite a week.  We decided to go into rematch with our au pair.  Mostly this was because the crashed our car three times (yes, three), and couldn't follow traffic signals (though somehow was "cleared" by a driving instructor we hired, which... bizarre?  Kind of like how cardiology will "clear" patients, like, "Patient is optimized (except for her uncontrolled hypertension, diabetes, and aortic stenosis.")).  We actually re-engineered our whole life at significant expense to us in order to accommodate not having a driver so we could hopefully keep her -- and not have to go through the process of finding someone else.  But in the end, there were other issues as well which... I will sort of get into later, that made me concerned about her priorities and her judgment.  (How's that for neutral language!)

So now we are in a quasi-scramble to try and find new childcare.  Since we ended up with this au pair because we had to rematch quickly with our last au pair (who my daughter loved, still loves, but who... um, hated me?  I think??) during a really heinous rotation during fellowship.  In retrospect, this was rushed, and I think we ended up with a bad fit as a result.

So now, I am resolved to take my time and find someone who is good.

At the same time, my job and our needs have changed.  I'm home more, so it's more important that I like talking to the person I'm sharing my house with.  If we're going to do this, we really DO need a driver (even though we can survive without one), because otherwise we can just hire a morning nanny and send Dyl to aftercare.

Which brings me to my next point -- I think we're really going to try doing after care and a morning nanny for a few months in order to give us some breathing room to find someone good.  I am having palpitations about this since I have never hired a nanny before... or done nanny taxes.  But, I have been encouraged by the response we've been getting thus far, and if push comes to shove, I can do the morning routine myself on non-OR days, and Luca can take Dyl to early care at school when I'm in the OR.  We think we found a place that can do aftercare for her as well.

So.

My question to myself is (and this is, er, related to the above issue with the current au pair, AND the former au pair): Why is it so hard to give feedback to people?  I think there are several reasons for this.

1) You doubt yourself!  What if you're feeling cranky about something someone does because you're tired.  Or you're cranky about something else entirely.  So you think, maybe I should not say something because maybe this is petty. I KNOW this happens to me.  I try really hard to hold it on the inside, but I know that other people can feel my vibe, even if I don't say anything.  I don't want to put the other person in the position of being my psychologist, so I self-censor.  But, it's possible they think that I am mad at them.  Thoughts on how to address this?  It comes up a lot, and I know I'm not the only one.  How do I suppress giving off the damn vibe or! (preferably) not have the vibe at all?  And how do I have more confidence that the things I want corrected should really be corrected?

2) You are afraid of conflict.  I absolutely suck when I do muster the courage to give feedback, and then the person disagrees or gives their rationale about why they think they are right.  I can usually deal with the questioning for a bit.  When it happens in the OR, I have been saying things like, "I can see why you might think that, but in this case...." or, "Yes, other people do it XYZ way, but I prefer ABC.  My reasons aren't necessarily evidence based, but I've found patients seem to do well with my approach," or, "You bring up a very good point, the reason is XYZ..."  or, "Let's please do it my way right now, and I'll explain later if there is time." But those are OR things.  Man I WISH someone had talked to me like that when I was a trainee.

But with the au pairs, I'll be like, "No, Dylan CANNOT have an extra 5 min of iPad for taking her dishes to the sink.  No it is NOT a new rule."  Then au pair disagrees, and I'm like, "You probably misunderstood.  We sometimes do things differently on the weekends, but despite what Dylan said, NO she does not get extra screen time." Then au pair disagrees again, and again, and again.  And finally I'm like, "Well, you are overruled.  Dylan OFF THE IPAD NOW."  When that happened, I was so mad!  And it made me more fearful of giving feedback in the future, because I feel like I have to be armed with an arsenal of backup knowledge just in case she pushes back.

3) You want people to like you.  Negative feedback often has the opposite effect.  I am getting better about this, in part because I keep telling myself that it's ok if not everyone likes me, and I am allowed to have preferences too, and that asking in a weird or passive way (and... giving off that damn vibe) is actually MORE dislikable than not asking at all.

4) And let's be honest.  Sometimes if you give a person feedback, their response is to complain to their boss about you.  They will say you are rude.  Or mean.  Or something.  I am TERRIFIED of having a "conversation" with my boss about something like this, and there is literally no recourse for me.  It is literally their word against yours.  I think... this can be toxic!

I think some people think that this would never be a problem for me because I will say what's on my mind in other contexts, which makes them think I don't care if other people like me, but I definitely do care.  It is something I could definitely do better.

What are your tips on handling your own emotional baggage when it comes to giving feedback, so that you a) do it, b) do it well, and c) don't perseverate on it?  Thank you in advance dear internet!  You've been hitting it out of the park with your advice to me lately!

Incentives

In May I got to attend my favorite policy conference.  This was the best year for me, by far.  I ran into people I know, had the courage to ask questions during panel discussions, and I did some networking.  Phew!  Attending that conference renewed my faith in myself, and solidified that yes I really do want to do health services research.  And yes, I will be able to find a job that allows me to do this.

One panel discussion I commented at was promoting the use of naloxone in the perioperative period as a quality indicator for hospitals.  For those that don't know, naloxone is the opioid reversal drug. We are trying to get people to use it MORE, in order to SAVE LIVES.  My issue is the introduction of adverse incentives surrounding the use of an emergency drug.  Some potential problems:

Inadequate dosing of pain medicine after surgery.  We spent decades under treating pain, do we really want to go back to that?  What's to stop hospitals from doing away from PCAs -- patient controlled analgesia a.k.a. the "pain button" -- and letting patients instead suffer in pain because nurses are too busy to administer a dose of opioid at adequate intervals of time after surgery?  The physician I talked to giving the presentation seemed to be unaware that PCAs even existed, and commented that they sounded horribly unsafe when I described them.  But in fact PCAs have been used for decades, and have a great safety profile.  Do you really want someone who doesn't even know how pain medications are administered in post-operative patients making health policy about pain medication use in the perioperative period?  I didn't think so.

What if we dinged hospitals for use of epinephrine because it was associated with adverse events (epinephrine is the drug you give along with chest compressions to dead people to make them not be dead anymore)?  The problem is, epi is an important drug with many lifesaving uses.  Why would you want to penalize hospitals from properly following resuscitation protocols?  Similar argument could be applied to naloxone use.

What's to stop hospitals from locking away the naloxone, and just intubating, mask ventilating, or good old fashioned sternal rubbing every patient who receives a bit too much opioid and stops breathing?  After all, the opioid will eventually wear off, and the patient will eventually breathe again.  All you need to do is maintain adequate oxygenation and ventilation until that happens, with or without the naloxone.  The problem is, many (most, IMO) physicians and nurses -- with the exception of anesthesiologists -- are terrible at mask ventilating patients.  Furthermore, some patients are difficult to impossible to mask ventilate adequately.  Same goes for intubating them.  What would happen is that hospitals would lock away the naloxone, and then patients would die preventable deaths that really should not happen inside a hospital just because someone could not adequately ventilate them in the setting of an overdose, and naloxone would not be available to quickly reverse the effect of the opioid to get them breathing on their own again.

The speaker told me that this would be unethical, and that doctors would never do such a thing.  I basically said bullshit.  Of course they would.  Someone would produce some crappy evidence that naloxone use actually led to some kind of bad patient outcome, and then all the hospital administrators would hang their hat on it without actually reading (or caring about) the methods as the reason that the naloxone had to be under lock and key.  Fortunately, a couple of other practicing physicians in the audience agreed with me.

Anyway, this is why I need to do health policy research with my life: to prevent people who don't understand how hospitals work from writing health policy and killing people by accident.

The end.

Go home

Last night I was on lates, which means I stay after the first batch of attendings goes home, but get to go home before the call people go home.

After I finished my two rooms, I asked the anesthesia coordinator/board runner: What can I be most helpful with here.  It seems pretty busy.

AC/BR: Don't worry, I will let you know as soon as I can if you can go home.

Me: Um, that's not what I asked.

We went back and forth a few times, we me suggesting that I could direct provide a case that had just  gotten added to the board.  I ended up setting up for it, and then got sent home.

So, in medical school, we learn that "What can I do to be helpful," is the polite way to ask to be sent home, since you CANNOT just go when you think you're done (even if you are done).  But then how do you ask to be deployed in a way that would be most helpful to the team if that is what you really want?

I don't understand indirect speak.  I really do not.

Pulling the trigger

I am not sure why I have such difficulty pulling the trigger on decisions sometimes.  I remember when I was 22 I bought a vacuum for $65 from Target (before Target was cool), and the belt broke on first use.  To be honest, fixing the belt was beyond me, but at the time $65 was a lot of money to me.  I probably should have just bought a new vacuum, but I was afraid that the next vacuum I bought would be just as bad as the first one, and I could not find it in me to spend money on a better one with a warranty or that would work. 

So I went without a vacuum for three years.  Then I moved into a place with hardwood floors and didn't need a vacuum.  Then I moved in with my husband who had his own vacuum.  That vacuum stopped sucking in approximately 2010, at which point (11 years after the first vacuum failure) I purchased a new vacuum.  And it worked great!  (We still don't use it very often because we have cleaners.)

Similarly, my first primary care doctor in Chicago was wretched and rude, with a rude office staff.  And I stuck with her even though it was clear she didn't like me for three years.  I think she hated her job (she told me she hated her job), hated doing gyn, and hated 20 year old women.  I finally found a doctor I like, but it took a really long damn time.  I think for some reason, they need to feel like I'm trying to be perky and social with them, but I'm at the damn doctor.  I shouldn't have to turn on the charm when I'm getting a pap smear. 

When Dylan was born we sent her to daycare.  Initially it was ok, but then the director got fired for embezzlement, a lot of the staff became disgruntled, and they were really rude, also.  There was always some form that had to be completed immediately (requiring a physician's signature, which is next to impossible to get on 24h notice).  I remember one time I politely asked if I could return the form a day later, and they threatened to kick me out of the center.  They were generally inflexible.  Finally, I remember going for some holiday thing, and I saw the teachers playing with and cuddling all the other children (whose parents were there too).  They barely acknowledged my daughter was present.  The other children were naturally much more outgoing -- the kind that run up to strangers and start climbing on them -- my daughter is much more reserved.  It broke my heart.  We finally switched her to a different nursery school and the difference was like day and night.  My daughter blossomed there.  My only regret is not listening to my gut and moving her sooner.

I felt similarly with our last au pair, who acted like she hated me (responded in monosyllables, rolled her eyes when asked to do things, when we asked her if she was ok or if we could do anything better she would stomp off to her room and not talk to us for a week).  We kept her because my daughter loved her, but she was like poison in my house.  She finally asked to rematch one day when I asked her to take my daughter to the pool three times, finally insisted, and asked her if there was a reason she didn't want to go.  She flipped out at me and quit.  We should have pulled the trigger months prior.

Why is it that I have such a hard time doing this?  Do you guys have any tips on how to make these sorts of decisions easier?