Friday, November 5, 2010

We See This Sometimes

Have you ever been to the doctor only to be let down with the words of the unknown/unexplainable "we see this sometimes." In Dr. Groopman's book, he presents a case of another doctor seeing a pediatric patient. He is uneasy at his findings but doesn't know exactly what to make of it. He even consults with a pediatric doctor who tells him, "we see this sometimes." The patient eventually ends up being diagnosed with acute lymphoblastic leukemia. The original doctor makes the following comment, "When you hear that sentence ('we see this sometimes'), reply, Let's keep looking until we figure out what is wrong or know the problem has passed." This is excellent advice.

If your doctor ever utters the words (or something similar), "we see this sometimes" and wants to leave it at that consider using the reply above. Another is to ask "what 's the worst thing that this could be. In asking what the worst thing this can be is, you are not being difficult or pessimistic but helping the doctor to generate at least one alternative diagnosis. A third question that could be posed to the doctor is "What body parts are near where I am having my symptom?" Be cautious in accepting a we don't know what is causing your symptoms diagnosis.

Dr. Groopman makes another excellent point when he says, "what we say to a physician, and how we say it sculpts his thinking. (This) includes not only our answers but our questions."

Do you have a story to share about having an unknown diagnosis?

Wednesday, November 3, 2010

Errors in Thinking

Have you ever seen someone and immediately jumped to a conclusion about him/her? Sure, we all have.

Dr. Groopman discusses some types of error in a physician's thinking. One of these is representativeness error. This error occurs when "thinking is guided by a prototype so you fail to consider possibilities that contradict the prototype and thus attribute the symptoms to the wrong cause." He gives the example of a man who presents to the Emergency Department with chest pain. From the look of him, he was a real outdoors man who was in great shape. His blood pressure and pulse were absolutely normal. A work-up for heart issues was all negative. The doctor diagnoses a muscle strain. The next day this same man comes in with an acute myocardial infarction (aka-heart attack). This is representativeness error in the physician's thinking. The man didn't fit the normal profile of a heart attack victim and his tests were all negative.

A second error in thinking that Dr. Groopman discusses in attribution error. He believes this is a more common error that occurs when a person fits a negative stereotype. You know, the guy who fits the bill perfectly for an alcoholic. However, this can be a mistaken stereotype. Perhaps, as the case presented in the book, the man has a rare disease. If the doctor just blows him off as another alcoholic, he will not diagnose or treat him properly.

Dr. Groopman makes an interesting statement in this chapter of his book. He says, "It (is) my job to be complete in my exam, and my charge to monitor my feelings when they might break my discipline."

As a health care provider, it is my job to be thorough and not to let my feelings cloud my judgment. I think we can all learn a lesson from these errors in thinking as we all fall prey to them at one time or another.

Any thoughts or stories of your own to share related to errors in thinking?

Thursday, September 16, 2010

What If You Can't Breastfeed

You have probably heard that "every woman can breastfeed her child." Well, I'm here to tell you that that is simply not true. Many of you may disagree but I can speak from firsthand personal experience with this.

I was so excited to be pregnant, and, like many pregnant women looking forward to breastfeeding my son. After a very difficult pregnancy and delivery I tried to get my son to latch so that we could start our breastfeeding experience. He wouldn't I had the lactation consultants at the hospital try to help me. I was told that my son had a high palate and my nipples were short. They had me try a nipple shield and start pumping. I should have known something was not right when I was barely getting any colostrum. I kept pumping faithfully and trying to get him to latch with the nipple shield. We started supplementing with formula because his blood sugars were low. By the time my milk should have come in I was lucky to be able to pump 20-30ml of breastmilk at one time (from both breasts combined). Needless to say I was devastated. I even saw a lactation consultant after I left the hospital. She told me she thought I had insufficient glandular tissue and would probably not get a full supply and she didn't know how much I would get. She thought the ounce I was getting at times was probably the most I would ever get. Again, devastation struck.

My mom told me that my grandmother had not been able to breastfeed any of her children (she didn't know why but I suspect this was the reason). Insufficient glandular tissue is thought to be genetic (although my mom breastfed me). In doing some research I also found that glandular tissue in pregnancy is tied in with progesterone. With some of the problems I had with my pregnancy I wondered if perhaps my hormone levels were fluctuating. There is no way to really know now. I have decided to talk to my OB/Gyn doctor at my next visit about this. Perhaps I will need to try something like natural progesterone cream in my next pregnancy (should the Lord allow me to have more children). I have read that natural progesterone cream used during a subsequent pregnancy has helped some women with insufficient glandular tissue. Of course, the lactation consultant also said that it improves with each subsequent pregnancy, but there is no way to know if I would ever get a full supply. I suppose I will have to pray about it and leave it up to the Lord.

My son is a happy, healthy infant who has thrived on formula. So, to those other women out there who have not been able to breastfeed because of this type of issue know that you are not alone (although it often feels that way). To those who can breastfeed, please don't judge those of us who are not because you never know why some women are not breastfeeding.

Sunday, August 29, 2010

The First Surgery

Genesis 3:18-24 (ESV)
The the LORD God said, "It is not good that the man should be alone; I will make him a helper fit for him."
So out of the ground the LORD God formed every beast of the field and every bird of the heavens and brought them to the man to see what he would call them. And whatever the man called every living creature, that was its name.
The man gave names to all livestock and to the birds of the heavens and to every beast of the field. But for Adam there was not found a helper fit for him.
So the LORD God caused a deep sleep to fall upon the man, and while he slept took one of his ribs and closed up its place with flesh.
And the rib that the LORD God had taken from the man he made into a woman and brought her to the man.
Then the man said, "This at last is bone of my bones and flesh of my flesh, she shall be called Woman, because she was taken out of Man."
Therefore a man shall leave his father and his mother and hold fast to his wife, and they shall become one flesh.

I'm always amazed when I read this story in the Bible. Who could ask for a better surgeon than the Great Physician?

Wednesday, August 25, 2010

Question & Think Like a Doctor

"Patients can learn to question and to think the way a doctor should," according to Dr. Groopman. Hopefully many of the posts to follow will show how to do this. I know, you think "there's no way I can learn to question and think the way a doctor should." But you may be wrong. Sometimes doctors rely too much on the "obvious" cause without really exploring all the possibilities. Don't be afraid to do some research on your own before you visit your doctor. If he/she seems to be dismissing what you say gently ask about other possibilities. Remember you are your own best advocate.

What do you think about learning to think the way a doctor should? Is it possible?

Friday, August 20, 2010

A Good Listener

According to Dr. Groopman, “How a doctor thinks can first be discerned by how he speaks and how he listens.” In the last post I gave the true story example of how one doctor listened. Let’s focus on how to tell a good listener. What characteristics would you give to describe a good listener? The following are a few of the characteristics I thought of in response to this question:

A good listener is active in the conversation. “I follow you.” “Uh-huh.” “Go on.” These statements all show that the listener is actively involved in the conversation. They also show that what you are saying is important.

A good listener will maintain some eye contact with the speaker. How often have you gone to the doctor and found that he/she was more intent on your chart than on what you were actually saying to him/her? This doesn’t mean that the doctor shouldn’t be making notes but you should notice some eye contact. I have actually seen doctors who have had their head buried in the chart or anywhere but on the patient for almost an entire visit. This drives me nuts!

A good listener asks open-ended questions. An open-ended question is an invitation for you as the patient to give your story. “What brings you to the office today?” is a good open-ended question. While you may have already told the nurse why you are there it is good for the doctor to give you a chance to tell him/her this information. Don’t get irritated by this and wonder “well, didn’t I just tell the nurse why I was here?” because this is a sign of a good doctor. I found this to be a most useful question when I was practicing as a nurse practitioner because not all patients are up-front with the receptionists or nurses about why they want an appointment. In contrast, a closed-ended question allows for only simple, usually one word answers, like “yes” or “no”. For example, “Do you have a fever with your sore throat?” This does not mean that there is never a time for closed-ended questions, but they should not be used the majority of the time. They may need to be used to ascertain more information once your story has been told.

A good listener avoids “why” questions. “Why” questions lead people to become defensive. There is always a different way to phrase a question to discover the same information without asking “why.” Try this with your kids sometime when you are tempted to ask a why question. Does it make a difference in how they answer you?

How did I do in my list of characteristics of a good listener? What would you add?

Wednesday, August 18, 2010

How Should Doctors Think

How did the book How Doctors Think come to be? Dr. Groopman participated in doing rounds with medical students and residents at the hospital. In the process he realized that the students and residents were relying a great deal on algorithms and evidence-based medicine. If you don’t know what an algorithm is think of a decision tree. You ask certain questions and if you answer “yes” you go on to a certain pre-set question and if you answer “no” you go another way and either stop asking questions or ask an entirely different pre-set question. You continue doing this until you reach a conclusion (diagnosis). This realization caused him to ask himself, “how should a doctor think?” In response he was forced to evaluate his own way of thinking and reasoning.

As an example of how doctors think he relates the true story of a woman who has been repeatedly diagnosed with anorexia and bulimia. Her family doctor finally sends her to a gastroenterologist (GI ). For the first time, this specialist really listens to her story and gives her hope. She has horrible stomach pain, nausea, and vomiting after eating and has been losing weight. She relates what she is eating to the doctor. It actually totals about 3,000 calories a day. Now, the specialist can choose to believe her and explore further to find out why she still isn’t able to gain weight, or he can choose not to believe her and label her with the same diagnosis of anorexia and bulimia. In the end, he believes her and asks “what am I missing”? She has some further testing done and receives the diagnosis of celiac disease. She is allergic to gluten which is found in many grains. After modifying her diet she finally starts to gain some weight and feeling better. This true story shows how a doctor’s thinking can radically affect a situation.

How does your doctor think? Does he/she think like the doctor in the true story?

Monday, August 16, 2010

How Doctors Think Intro

While I’m getting my act together and working on some more posts I thought this would be a good time to delve into a series about good book that I found at a library sale a while back. The book, How Doctors Think, was written by a Medical Doctor named Jerome Groopman. I hope you will find this useful. I think you will.
Dr. Groopman starts the book by talking a little bit about evidence-based medicine. “What in the world is evidence-based medicine?” I’m glad you asked. The premise of evidence-based medicine goes something like this…you have evidence (statistics) that show that your chosen plan of treatment is the “best” for a particular issue. For example, let’s say you want to know which of these 3 medicines best treats condition X. You will have 4 groups you study. Group 1 takes medicine A. Group 2 takes medicine B. Group 3 takes medicine C. Group 4 takes a placebo (sugar pill). The placebo group doesn’t know that they aren’t really getting an actual medicine. You follow these groups to see which one(s) have the best outcome. (This is a simplistic example but you get the idea…). Dr. Groopman makes the following statement about evidence-based medicine and statistics, “statistics cannot substitute for the human being before you, statistics embody averages, not individuals.”

I already like this doctor. Don’t you wish more doctors were like him? Now, does this mean that the health care field should throw evidence-based medicine out the window? No! It just means that those of us in the medical field should still use our God-given brains and think and reason. We need to listen to our patients (more to come on this topic). Just because something should work based on statistics does not mean it will work in any given individual. If it is not working, we need to try something else.

What do you think about Dr. Groopman’s statement? Would you want him (or someone like him) as your doctor?

Sunday, August 15, 2010


Genesis 1:1-2:3 gives us the story of creation. It starts, In the beginning, God created the heavens and the earth. From there it proceeds to tell us exactly what God made on which day.

Day 1—Light & Darkness/ Day & Night

Day 2—Heavens

Day 3—Earth, Seas, Vegetation/Plats

Day 4—Sun, Moon & Stars

Day 5—Sea creatures/Fish & Birds

Day 6—Livestock, Creeping things & Beasts of the Earth and Man

Day 7—God rests

Why start my Spiritual emphasis day (Sundays) on my blog with Creation? Because my belief in creation affects my personal view of health and of caring for my body and for my family. Perhaps I can share more about this in a future post.

What has shaped your view of health?

Friday, August 13, 2010

Journey to Mommyhood Part 6

Being a nurse I wanted to avoid major surgery if at all possible so I opted for the epidural and trying the vacuum. (What fun it was to sit up, sit still, and not push through contractions for the epidural…but the anesthesiologist was great and I think it was only 3 contractions before it was in and they were laying me back down). When we got to the OR William’s heart rate promptly dropped a couple of times so the doctor was not comfortable trying the vacuum so they got things set up, gave me a little more medication in the epidural and we had a C-section. William did not cry immediately and looked blue and kind of floppy but the nurses were great and he cried before too long. After Eric left and they were finishing the C-section the nurse asked the doctor if she had seen the placenta. I asked her about this later and she said that the umbilical cord was implanted in the sac and then branched off into the placenta (this is called a velamentous insertion and occurs in only about 1% of singleton pregnancies). She told us that William was a miracle because a lot of babies don’t survive when the cord implants like this. In doing research on this, a velamentous insertion can be associated with abnormalities in the baby. As far as we can tell William is perfectly healthy with no issues.

My recovery was longer than I had hoped for. It took about 8 weeks for me to feel a little more normal. On top of major surgery, I had hormonal shifts and a newborn to care for.

How have you weathered the hormonal shifts after giving birth?

Wednesday, August 11, 2010

Journey to Mommyhood Part 5

I saw my OB doctors every week at this point and stayed on the terbutaline until I was almost 37 weeks. On March 31 I stopped taking the medicine. I mad it until April 5 when I woke up around 5 am with contractions every 4-8 minutes apart. I didn’t want to wake Eric so I just laid there keeping track of how close they were and waiting for his alarm to go off at 6 am. When I called my OB doctors around 7 am I was told to go to the hospital to be checked to see if this was indeed labor (although I had no doubt). We finished packing up some things and headed to the hospital.

I had decided to try to have a natural birth with no medications. When I arrived at the hospital I was 4 cm dilated and was admitted in labor. I was put on the monitor until they were satisfied that everything looked ok with the baby and then was taken off for almost an hour. However, when I was put back on the monitor they weren’t completely happy with how the baby looked so I had to stay on the monitor in bed just getting up to go to the bathroom. By the afternoon I was still only 4-5 cm dilated and the doctor wanted to break my water. I was not thrilled with this idea but gave in. Oh boy, did the contractions ever get painful (not that they weren’t before…they were just worse). My contractions started coming one on top of the other…like only a minute or less apart. So once again I was given a shot of terbutaline because this is way too close together. It was kind of funny when one nurse was looking for the Pitocin on the IV so she could turn it off. (Nope…sorry no IV Pitocin here just the natural stuff). By 3-4 hours later I only had a little bit of cervix left that she was able to push around the baby’s head. I started pushing. What a relief pushing felt. However, the baby’s head was turned to the side and wasn’t rotating like it should. I had to stop for 30 minutes or so because the doctor had to go to another delivery. The nurse actually let me push on my side when I felt the need since I didn’t have an epidural or any pain medication. Change of shift came and I was still pushing. Then there was a big discussion about the monitor strip. (I’ll spare you the details). William’s baseline heart rate had dropped and was dropping with every contraction. My options were to 1)get an epidural or spinal and go to the Operating Room to try a vacuum and if unsuccessful do a C-section or 2) just do the C-section.

Given the options I had to choose from what would you have done if you were in my shoes?

Monday, August 9, 2010

Journey to Mommyhood Part 4

At my 28 week appointment I once again mentioned the contractions (which I thought were Braxton Hicks). The doctor decided to check my cervix. She said it was soft but long and closed. Since my uterus was measuring a little smaller than it should she sent me for an ultrasound to check my fluid levels. This ultrasound showed that the baby was really low (the tech had a lot of difficulty getting a head measurement because he was so low but finally did). My fluid levels appeared fine and my cervix was long and closed.

I think I mentioned the contractions again at my 32 week appointment only to be told that the ultrasound had showed that my cervix was long and closed. She never checked me at this appointment. (By the way, the fact that my cervix was soft at 28 weeks probably should have been considered abnormal as this normally does not happen until much closer to labor). So…I kept doing my normal daily stuff (with lots of breaks to sit or lie down). On March 5-6 we had our childbirth class. When we got ready to go to the class on Saturday morning, March 6, I noticed that I had some mucus with just a little blood when I went to the bathroom. Since a woman can lose some of her mucus plug a week or more before labor I tried not to think too much about it. However, during the childbirth class I kept having pretty regular contractions. When we left the class around 5 or so I called the OB on call who told me to come to the hospital immediately. (He sounded kind of panicked when I talked to him…especially since I was only 33 ½ weeks at this point). When they put me on the monitor at the hospital I was contracting every 3-5 minutes (feeling them all in my lower back). My doctor had the nurses give me a shot of terbutaline (which worked for about 5 minutes). When he checked my cervix he said I was 3 cm dilated and 80-90% effaced. (Basically my cervix was thinning and opening in preparation for birth). I was admitted and started on Magnesium sulfate via IV to try to stop my labor. I ended up on that for 2 ½ days and then switching to terbutaline pills every 4 hours. All total I spent 5 days in the hospital. I was sent home on the terbutaline and on bedrest. My due date was April 22, 2010.

Have any of you been hospitalized during your pregnancy? How about on bedrest? How did you handle this?

Friday, August 6, 2010

Journey to Mommyhood Part 3

On December 4 I had my 20 week ultrasound where they once again told us we were having a boy. Nothing seemed out of the ordinary but then around the December 10 or 11 I started feeling like it was hard to breathe. I was only about half way through the pregnancy so it was too early for it to be the uterus pushing on my lungs and diaphragm. I had an appointment scheduled with my OB for December 14 so I waited it out. Since I had been diagnosed with exercise-induced asthma as a young teen she said the pregnancy had activated this and gave me a prescription for an antibiotic (z-pack) and an inhaler (albuterol). I took the antibiotic and used the inhaler but in 2 weeks still was not any better. My OB office told me to go to my primary care provider (PCP). So…I made an appointment and saw the nurse practitioner there. I ended up seeing her twice. Taking another z-pack, then taking another antibiotic and using a steroid inhaler (Advair) with the approval of my OB doctors. None of these things seemed to make my breathing that much better. Some days it would be really good and I would think that it was improving and then it would get worse again. This would be an ongoing struggle until about 2-3 weeks after I delivered. On top of this I was having some contractions pretty much every day. They weren’t that painful (just kind of uncomfortable) and they weren’t regular so I just mentioned them to my OB starting around 24 weeks. Again, I wondered if something was wrong.

Have any of you had preterm labor?

Wednesday, August 4, 2010

Journey to Mommyhood Part 2

Eric & I went to the appointment. I was sure that I was going to be given devastating news again. However, when they did the ultrasound there was the baby with a strong heart beat. The doctor thought I wasn’t quite as far along (by about 5 days) as we had thought and wanted me to follow up in 2 weeks for a repeat ultrasound to check the dates. On September 16 we went for the follow up ultrasound. A different doctor did this ultrasound and said we should just stick with the original due date since the discrepancy was only a few days. Everything looked fine. He did see a pocket of what he thought was blood that would explain the bleeding. He said it is not out of the ordinary for a woman to have bleeding in the first trimester and he thought that the pocket was part of implantation. He told us that this can happen and can either be reabsorbed or could cause bleeding like I had been experiencing.

Around the end of September or beginning of October I once again experienced painless bright red bleeding. It was on a Saturday and since I was still in the first trimester I waited until Monday and made an appointment with the OB office. Again I was told that it is “normal” for some women to have bleeding during the first trimester. I ended up calling back about a week later to see if the doctor would order an ultrasound. She did but I had to go to an outpatient radiology office to have it done. So…around 13 weeks we had our third ultrasound. The tech even asked us if we wanted to know what we were having. We had decided to find out so she told us it was a boy. Eric said he knew as soon as she asked that it was a boy because they couldn’t be so certain at 13 weeks if it were a girl. That ultrasound did not show any reason for the bleeding but the doctors weren’t too concerned. I, on the other hand, kept thinking that something is not quite right.

Did you opt to find out your baby's gender or to be surprised?

Have any of you had feelings that something was not quite right during your pregnancy? Were they accurate?

Monday, August 2, 2010

Journey to Mommyhood (Part 1)

I thought I would start this blog by sharing my pregnancy and childbirth journey. Since it is rather lengthy I will be sharing it in increments.

In August 2009 we found out that we were expecting. We were excited but a little tentative also. You see, we had thought we were going to have a new little one in our home in October 2009 but I ended up being diagnosed with a blighted ovum and having a D&C right before Valentine’s Day because my body was not miscarrying on its own and I was at the 10 weeks “pregnant” point. If you don’t know what a blighted ovum is basically the egg and sperm meet and things begin but do not continue as they should and no embryo ever forms. We had 3 ultrasounds before we had the D&C…just in case the dates were off. This was a difficult time for me. So while I was excited at this new pregnancy, I was also a little on edge.

My first OB appointment was on August 25, 2009. They did the typical first appointment stuff…took my history, asked if I was sure about the dates, drew bloodwork, etc. I received the call a day or two later that I was indeed expecting and the bloodwork looked fine.

The next week I started nursing clinicals as adjunct faculty for a local University. That morning I woke up and didn’t notice anything out of the ordinary until I went to the bathroom. Then I noticed bright red blood. My heart sank. I had to go to clinicals…there was no one to take my place. This was a difficult day for me, to say the least. But I was able to schedule an appointment with my OB the next day for an ultrasound.

Have any of you had first trimester bleeding or other complications with any of your pregnancies?

What medical topics are you most interested in learning more about?

Saturday, July 24, 2010

Welcome to Good Gesundheit

I’m a Christian nurse practitioner now stay-at-home mom to my son who is the joy of my life. My husband is my best friend and a huge source encouragement to me. This blog came about after my very difficult pregnancy (more to come on this in the blog). I hope to be able to share medical information about various topics in a down-to-earth way (please be sure to read my disclaimer).

Why the name Good Gesundheit? My much more creative than I am husband suggested it after the name I wanted to use was not available as a blog name. Gesundheit is the German word for health…hence the name Good Gesundheit (Health), not to mention that it’s kind of catchy.

Be sure to look around my blog. I have some ideas and long-term goals in my Vision for My Blog page. I hope you will visit often or even hang around a while.

You may contact me at or by leaving a comment on my blog. I look forward to hearing from you.