Despite our water-based adventures that morning, I still had plenty of time to get ready for work and to eat a small breakfast and prepare my lunch before my clinic started at 8 am. My clinic schedule for the day was jam-packed with an eclectic mix of patients:
8:00 and 8:20 - 6 month old twin girl well child checks one after the other at the start of the day
8:40 - 46 year old female with diabetes
9:00 - 72 year old female with hypertension, depression, diabetes and follow up osteoporosis
9:20 - 26 year old male for follow up HIV PrEP
9:40 - 24 year old new patient to establish for transgender hormone therapy
10:20 - 32 year old male with depression/anxiety
10:40 - 16 year old male for a sports physical
11:00 - 36 year old female with an acute respiratory tract infection
11:20 - 22 year old transmale for follow up hormone therapy
11:40 - 32 year old female with UTI symptoms
The afternoon was equally packed, and equally varied, with a few more anxiety/depression patients thrown in for good measure. When I had joined my residency program 2.5 years ago, I had made sure that serving the LGBT community would be apart of my training, since I knew that this was a community that I wanted to serve when I "grew up." But I really never expected to be able to see such a wide variety of LGBT patients in Salt Lake City, owing in large part to my own preconceived notion of what "type" of people lived in Salt Lake. I was thrilled to be wrong.
I particularly enjoyed working with my transgender patients, who had backgrounds as diverse as the medical ailments present on my schedule this morning: some came from families who were incredibly supportive, others who had been disowned by their "birth families" but adopted by their chosen families. Some who had known that they were trans since they were three years old and others, who had figured it out much later in life, sometimes in their teens or twenties, some even as late as their 50s. Ethnically, my trans patients were maybe less diverse, but I still had patients from Polynesia/Hawaiian Islands, Latinx, and a very small handful of African-Americans.
The other thing about caring for the LGBT population was that it was a small break from the mental hardship that goes along with serving the economically disadvantaged, namely my refugee and Medicaid patients. It's not that I did not enjoy serving this population – on the contrary, I often looked forward to seeing these patients, helping in whatever way I could – it's just, it takes its toll on you, as a provider, to know that what ails your patients isn't really diabetes, or depression or heart disease but larger more endemic problems like poverty and loneliness, and to know that small adjustments to their diabetes medications or to their anti-depressants, are not likely to make those bigger issues go away.
In fact, with my trans patients, it was just the opposite: you got to be ring-side as they discovered the fullness and beauty of who they really are, and to see them come out of their shell and explore their world authentically, unapologetically and with such indominable fierceness! It truly was the greatest gift that they gave to me, to let me be a part of their journey.
The other part of my LGBT patient population was divided 80/20 with mostly young gay men on HIV PrEP and older lesbians who were primarily professionals. I enjoyed these interactions too, since for the most part they were healthy, and doing well, so we could sometimes spend our visits chatting about this or that, without having to rush from one disaster to another.
Today, as I looked at my schedule, I knew that my 9:00 patient would pretty much derail the whole day. She always had a lot going on, and boy was she a talker. I was glad that there was an "easy" PrEP patient after her, followed by a new trans patient, as this meant that there was a chance that I could make up some lost time that would inevitably occur during her visit.
Sure enough, by 9:15, she was only just getting roomed, since the immunizations for the twins had taken a long time to get together, and the HgbA1c machine (that we use to monitor patients with diabetes) was on the fritz. These delays had made the 8:40 diabetic patient run long. By the time I got into the room it was already 9:37 and I could tell just by looking at her that I would likely be in there for an hour.
One of the cruelest parts about aging in America is that most elderly adults are lonely, and that is precisely what her problem was. She had never married, had no children, and did not have any relatives in Salt Lake. Her diet consisted primarily of McDonald's, other fast food, and cheap frozen dinners, since she didn't know how to cook and that was all her budget would allow. She was morbidly obese, and as a result, had arthritis in her knees, hips, wrists, neck and back, and her blood pressure was difficult to control because of her frequent dietary indiscretions and because she inconsistently took her blood pressure pills.
I reviewed her vitals in her chart, which showed that her blood pressure was very high today at 167/97 and she reported to my MA a host of new problems: worsening pain in her neck, difficulties paying for her medicines and problems tolerating one of the medications for her diabetes.
There was no way that we were going to be able to address all of these concerns, and I could just tell that there was something else too, because she wouldn't meet me gaze when I shook her hand, and she was folding and unfolding a tissue in her lap.
I greeted her warmly, and shook her hand, pushing the computer away, since signing on and starting to chart was clearly not the best way to start our encounter today. "Good morning Linda, it's so lovely to see you. What can I help you with today?" I asked, trying to sound as warm and upbeat as possible.
"It's... well, my dog died three weeks ago, and I just..." she said, and then she started crying in earnest, unable to get the words out through her tears.
We had known each other for several years, and had had several interactions like this, so I knew that she would be ok if I touched her, so I scooted my stool closer to her and offered to give her a hug with open arms. She accepted and wrapped her arms around me and just cried for a full minute. I didn't say anything, or offer any kind of suggestions, I just let her feel my presence, let her know with our contact that I acknowledged her existence and her need to grieve for the loss of her dog, who had likely been her sole companion for many years. Gradually, she collected herself and pulled away.
"I just don't know what to do," she said, "I can't imagine my life without him. I haven't been sleeping or eating or taking my medicines at all for the past two weeks, I've just been in this fog." She wiped her nose with the tissue and looked up at me with her blood shot eyes.
"I know it can seem kind of sudden, but have you thought about getting another dog?" I asked, positioning my rolling stool so that I was still close to her, but so that we were no longer directly in each other's face.
"I'd like to, eventually, I just can't afford any extra bills right now, I'm having enough trouble as it is paying for my own meds," she said, looking down at the tissue again as she folded it and unfolded it over and over.
"Well, I hope that we can help you there," I said, scooting back to the computer to open her chart. "Why don't we have you meet with our clinical pharmacist and we'll see if she can't find some less expensive alternatives. I know that you've been having problems tolerating one of your diabetes meds, so it's probably time to think about other options anyway."
She nodded but did not look up.
"I'd also like to explore the idea of putting you on an anti-depressant," I said, cautiously broaching this topic again, as this had been an area that we had danced around one or two times before. "I understand that you have reservations, and I hear you, but Linda, I'm worried about you. I think some of what you may be feeling is because of depression, and that if you were less depressed, some of these other problems might not seem so insurmountable."
She nodded again, this time looking up briefly to meet my eye. "I thought you might bring this up again, and so I thought about it before coming here today, and I think you're right, that it's time to try something."
I proceeded to talk with her at length over the pros and cons of selective serotonin reuptake inhibitors (SSRIs) and finally we decided on celexa, which was generic, and therefore very inexpensive. We also arranged for her to meet with the clinical pharmacist, and I had my MA show how her to use a pill reminder app on her phone, so that she could be prompted to take all of her medicines daily. I had her schedule an appointment in two weeks to follow up with me and finally I exited the room at 10:10 – meaning I was 50 minutes behind with two patients waiting.
I flew from one room to the next, and greeted my next patient with another warm handshake and a sincere apology about the delay. He was also well known to me, and had clearly planned for this possibility, because he smiled warmly at me, and shrugged it off.
"So Daniel," I said, pulling up the computer so that I could start charting and get myself back on track, "how are things going with your PrEP?"
"Great," he said, putting his phone down, and crossing his legs, "no problems really at all."
"Are you having any problems remembering to take it?" I asked, typing his responses quickly into the computer.
"None, I put it next to my toothbrush like you said, and that seems to help me remember. I also put aside 3-4 pills in a little emergency container in case I'm not near my toothbrush in the morning."
"How many times in the past week have you missed a dose?" I asked, continuing to chart his responses.
"None."
"In the past month?"
"Maybe one, but because I had that little emergency supply, I just ended up taking it later that same day."
"And who are you having sex with? Any new partners?"
"A few random guys I met at a club, and then pretty regularly with my on again/off again boyfriend, and some friends that we, you know, party with." He reached down to take a sip from the water bottle at his heel.
"What types of sex are you having? Top, bottom, oral, vers?"
"Yes, yes, yes and yes." He said with a smile.
"And what, besides PrEP, are you using to protect yourself from HIV?" I always asked this question this way, instead of saying, "do you use condoms?" because it allowed for the answer to be "condoms" but also allowed for people to say things like "communicating with partners" and "talking about PrEP" which were equally important ways to combat HIV transmission.
"I'd say that I use condoms about 20% of the time, mostly with the randoms at the clubs. The other 80% is with people I know well, and we generally don't use condoms."
"Are you concerned that you were exposed to HIV in the past three months?" I asked, as I typed in the last few parts of our encounter.
"Nope." He said, unfolding his legs and putting both feet on the ground.
"Any new concerns for me about PrEP or any other concerns you want to address today?" I asked, hoping and praying that he didn't have a "well I have been having some chest pain lately" kind of question just as we were finishing up.
"Nope, I'm good."
"That's great. Let's collect swabs from your throat and your rectum for chlamydia and gonorrhea, and then you can give us a urine sample before heading to the lab to get your blood drawn for your HIV test and kidney function test."
I moved to the drawer beneath the exam table and pulled out two Aptima tests that we used to collect the chlamydia and gonorrhea samples, then pulled his stickers from the metal clasp next to my computer and handed the stickers for him to verify his identity.
"That's me!" he said, handing the sticker sheet back to me.
I grabbed a pair of gloves and proceeded to swab the back of his throat, and put this in the tube labeled "oral" and then had him turn around, drop his pants, and bend over, so that I could swab the first inch of the rectum, placing this in the tube of the same name.
He pulled up his pants and started buckling up again, as I was pulling off my gloves. I moved over to the sink to wash my hands, then dried them using the nearby paper towel dispenser.
"Sounds like things are going really well, I'll contact you with the results tomorrow, and let's plan on following up in three months."
"Sounds good, Dr. Parks, I'll see you then."
We shook hands, and I left the room, moving directly from that room into the next room. The time was 10:18, so I was only 40 mins late for my next appointment.
I walked into the room and saw that there were two people seated side by side. I greeted each of them by shaking their hand, then asked, "I understand that we're establishing care with Crystal today, which one of you is Crystal?"
"I am," Crystal said, raising her hand and smiling nervously.
"It's really nice to meet you Crystal, who have you brought with you today?" I asked, as I booted up the computer to begin taking her history.
"This is my sister Rebecca," she said.
"It's very nice to meet you both," I said, "Crystal, I understand that you're here today to discuss transgender hormone therapy, is that correct?"
She nodded.
"Before we get started, I wanted to make sure that you are ok with having Rebecca in the room? We're going to need to discuss some very personal things about your health including your personal history, your sexual history, your sexual practices, but also things like drugs, smoking and alcohol and also topics related to mental health. Is it ok with you if we talk about these things in front of Rebecca, or should we have her wait outside?"
"It's ok," she said, "it's cool, she can stay, she knows it all anyway."
"That must be nice to have such a supportive sibling, I'm glad that you brought her with you today," I said, opening her chart so that I could begin typing. "Well, to start, before we get too much into your history, I'd like to tell you a little bit about how this works, and what we will and won't accomplish today, is that ok?" I asked.
Again, she nodded.
"We're going to start by getting a history from you – asking things like when did you know that you were trans, and how you managed those feelings, and who you told, and how that went, and you've been doing since then, all of which helps me to understand what your journey has been like. Everyone has their own journey, and I'd like to understand a little bit about what yours has been. Then we're going to talk about how we do hormone therapy in this clinic, namely how we provide hormones through the 'informed consent' model and that we will provide you with this document today, but we won't have time to go over it at today's visit, so we're going to want you to look over this at home and when you come back for your follow up visit we're going to review it in great detail to make sure that all of your questions have been answered so that you can make sure that you are making the right decision for you. Then we'll talk about the need for laboratory monitoring and regular office visits, especially during the first year of your transition, so that we can make sure that things are proceeding smoothly and that you are seeing the changes that you want to see, but not having other difficulties or side effects. You will not be prescribed hormones at the end of today's visit, owing to the amount of stuff we need to cover. Finally, before you leave, we're going to want to get some lab work, and we will review this next time as well. I also want to review the questionnaires that you filled out while you were waiting, and make sure that there is nothing there that we need to address. Any questions before we get started?"
She shook her head no.
"Let's start by you telling me when you first knew that there was something that was different or special about you, and how it is that you learned that you were transgender?" I asked, positioning my hands above the keyboard so that I could type out her story, haiku-style, in my note.
She proceeded to tell me that she had been born male and didn't really feel anything different compared to other kids until she was about 11 years old and she started going through puberty. At first, she thought that she was gay, because she found that she was attracted to boys, but as puberty progressed, and her body began to change, she felt more and more like her body was moving farther and farther away from how she saw herself. She had been raised primarily in California but had moved to Salt Lake when she was 15 and attended high school at Skyline. At that point, she had come out to friends and family as "queer", but she knew that there was more to it, she just didn't know what it was.
She went away to college to a small liberal arts school in the Midwest and majored in Graphic Design. By her second year, she had fell in with the "theater kids" and there was another transwoman in her social circle. Gradually, she felt comfortable enough to start asking her some questions, realizing that something really resonated inside her with the answers she was given. So she did lots of research online, and sought out even more transwomen, and a few transmen, through the local Pride chapter at her school. By her senior year, she had been living has a woman for a year, but had not wanted to deal with hormones, primarily because there was no one at her student health clinic who would prescribe them, and she would have had to travel into one of the larger nearby towns for access to these.
When she returned home after graduation, and came out to her parents as trans, they were not as supportive as she hoped they'd be. They did not disown her, but they refused to pay (through their insurance) for her medical transition. She worked in several odd jobs, but always part time, and so could not afford to pay out of pocket to see someone for hormones and did not work anywhere long enough to get on an insurance plan. Finally, three months ago, she got a steady job, and her insurance benefits had kicked in last month, and she wasted no time in making this appointment, as she was eager to get started with hormone therapy.
She reported that she was sexually active with cis-men, mostly, and that she exclusively bottomed and performed oral sex. She generally used condoms, but sometimes, if her partners were insistent, she did not. She was ok with getting STI testing, and had never heard of HIV PrEP, so we agreed that I would provide her with some information on the subject, and that we would schedule her follow up appointment quickly so that we could start PrEP, if she felt that was appropriate, after she had reviewed the materials.
She didn't smoke, drank occasionally, smoked marijuana mostly on the weekends and had no other medical history other than molar surgery and having her tonsils out when she was a kid. There was no other family history, surgical history or mental health history. She had no allergies and took no other medications.
I explained to her how hormones were provided in our clinic, printed out the "transfeminine hormone therapy consent form" for her to review, and again had her make sure that it was her name on the identification stickers, before we collected the samples for STI screening.
"The STI testing we're going to do requires that we take samples from the back of your throat and from your rectum. I know that you said that you don't engage in sex with your penis, but I would still recommend that we collect a urine sample, just in case. If you like, I can collect the samples from your throat and rectum, or I can just do the throat, and you can collect the sample from your rectum, whatever makes you the most comfortable."
"I'm fine if you do it," she said.
"And this is where I peace-out," said Rebecca, "see you in the lobby Crys."
As before, with my earlier PrEP patient, I dawned some gloves and carefully collected samples from her throat and rectum, then removed my gloves, washed my hands and invited her to wait in the room while I went to get my MA.
The time was 11:08, and I was back to being about 50 mins behind and two patients down.
Luckily the next two patients were pretty quick and the final three were all pretty straight forward. I walked out of my last clinic of the morning at 12:45, leaving myself 15 minutes to close all my charts, answer all of my messages, review all of my labs, eat lunch, pee and drink some water all before my afternoon session started at 1:00 pm.
There were days, when I just wanted to work an office job, and this was definitely one of them.
By the time my evening session ended at 5:40, I was utterly exhausted. The second half of my day had proceeded not unlike the first with too many patients, squeezed into too small of a time slot, with too many problems to manage, in too little time. I walked into the back room, to staff the remaining patients with my attending Dr. Nelson, and I could tell that she could sense that something was wrong.
"How you doing?" she said calmly, turning her chair to look at me as I slumped over in a chair across from her.
"My brain is absolutely fried; I honestly don't think I am cut out for this line of work."
She nodded slowly, but didn't say anything, leaving space for me to continue.
"I just feel like the day is set up in a way to guarantee that I will never run on time and that I will never have all of my notes done, and my charts closed, and my messages answered and my forms signed and my results reviewed all in a timely fashion. How do you do this day in and day out for years and years on end? I think I would go crazy." I leaned my head back to stretch out my neck and brought both hands to my face to rub out the tiredness in my eyes.
"Well, for starters, I don't," she said, leaning with her elbow on the arm rest of the chair nearest me. "Long ago I realized that I wasn't cut out to see 40 patients a day, five days a week, and I knew that I had to find something else that I could do that would allow me to chip away at the time that I spent in clinic. So I got a job in a family medicine residency program, where some of my duties take me out of direct patient care and involve teaching you guys how to do it – or maybe how not to do it – and also teaching medical students, and other students. I also participate on several committees and do a little bit of research, but not enough for that to really pay the bills. So, believe me, I know what you mean. This is hard. Let's acknowledge that. But let's also reflect just a tiny bit on what you did, and did not, accomplish today, sometimes this helps."
I turned around and opened my computer and pulled up my schedule. We carefully went over each patient from the afternoon session and I told her about them, and what my plan had been, and she made a few comments here are there about alternative medical management and some notes on my documentation and billing. When we had finished with this list she said, "it looks like you've got about 40% of your notes closed. What do you think was your biggest barrier in finishing those as you were moving throughout your day?"
"I had a few patients who just completely derailed me and I was running about 50 mins behind. Also, everybody showed up, so I didn't have any breaks, it just felt like I was moving at 150% speed all day without a moment to chart in between."
She nodded. "Show me the chart from the respiratory tract infection this morning, the one at 11:00. How much of that note do you have to finish?"
I opened the chart, and reviewed what I had already completed: I had jotted down a few things in the patient history, hadn't yet documented the physical exam that I had performed, and I had not finished the end of the note with the "assessment and plan." But, I had put in all of the orders (of which were only two) and put in the diagnosis codes and some patient instructions.
"Here's what I want you to do," she said, "I want you to pretend that you've just walked out of this patient's room and I want you to close this note by filling in all of the parts that are missing. I'm going to look away, so that you're not intimidated because I'm looking over your shoulder, but I am going to time you."
I did what she said and quickly typed out the physical exam and created the brief assessment for the patient, using the patient instructions that I had already written as proof of my plan. When I finished, I turned to her and she looked at her watch. "Not bad," she said, "you finished that in 1 min 40 seconds. Do you think that your next patient would have noticed that you were 1 min and 40 seconds later, given that you were, at that time running 50 mins behind already?"
"No, probably not, but it seems very selfish to make them wait when I am the one who is running behind."
She nodded, but again, waited a moment before speaking, I think in case there was anything else that I would want to say. "The problem with that logic is that it leaves us where we are now. It's already 6:15 and you've got at least 2 maybe 3 more hours' worth of charting to do before you'll be done with today's work. If you do that every day for five workdays, that's 15 hours, most likely you'll need to carve out that time on the weekend or maybe when you go home tonight. That's 60 hours per month and 240 hours per year and 2400 hours in ten years. That much time is a career killer. It will start to eat away at you, and make you resent this job, and resent your patients. That much time is poison, and it will slowly kill off any love you have for this job or this life or this profession. If there is one thing I want you to learn in residency it is this: you need to get your work done at work, and then you need to leave work, and go home and be someone else. Be someone who does not do work at home. If that means that your patients have to wait 1 min and 40 seconds longer for you, so be it. But I guarantee that if you do not learn this, you will get one or maybe two years into your career and you will be burnt out. This job isn't for the feint at heart, or for slow typers, or for people who are inefficient in time management. But the good news is that you can learn to type faster and you can learn to be more efficient. You just need to put into practice some behaviors that will serve you well, including closing your notes after each patient, and doing as much as you can while you're here, at work, so that you save something of yourself for when you get home."
I turned back to face my computer, then looked at my watch, it was 6:21. Andy and I had agreed to meet up at my house at 6:30 for our special date.
"So what do I do about tonight? My boyfriend and I are supposed to do something special, and I still have three hours more of charting left to do. Do I stay here and get it done, or do I leave now and do it later at home?"
"I can't answer that for you, everyone approaches this differently. Some people leave at the same time as the last patient and they go home or to the gym and they take a breather for a minute, an hour, maybe more, and they chart from home. Some stay until the work is done. Some come in early. Some, like me, decide that they're just not going to work as much, and they cut back on their hours. Some talk less with their patients, or limit their patients to one complaint at a time, some write very brief notes, some use dictation software, some go into concierge medicine, some join pharmaceutical companies or go into research and stop seeing patients altogether. You need to find a strategy that feels right to you, but as much as is humanly possible, I want you to chart while you are here, even if it makes you late for your next patient."
I nodded, and turned to my computer, to the mound of work that I still had left to complete, then looked at my watch again, it was 6:25. I exited the electronic medical record and turned off the computer. "I think tonight, I'm going to go on my date with my boyfriend, and I'll look at these later."
She smiled, and turned her chair to face her own computer, "that sounds like a terrific idea. Have a good time."
I picked up my coat, my purse, my empty lunch sack and my bottle of water, and pulled out my phone to text Andy.
"I'm running late, but I'm on my way! Be at my house in 5?"
By the time I got to my car, he had texted me apicture of him and Max lounging on my back porch, he with a beer in his hand,and Max with a dog bone balancing on his nose. It was captioned with, "we eagerlyawait your imminent arrival." I laughed silently at the picture, opened my cardoor and drove away, looking forward to the "me" that I would become when I gothome.