I Left My Heart In ...

Unless you are in the Bay Area, you may not have heard all of the hullabaloo stemming from a Facebook comment by a restaurant patron here in San Francisco about taking children out to eat in public dining venues.  So as not to bastardize, let me quote directly.  After an, apparently, particularly disruptive experience at a small sushi bar in the Cole Valley neighborhood, this diner said:

This may shock you, but choosing to have children means you can't go out to eat for roughly three years.  Please.  Accept your fate -- you're killing me. 

The hubbub that ensued was not just because this -- kind of hilarious and kind of true statement -- was simply offensive to some in its own right (which it clearly was), but because Jennifer Bennett Piallat is the owner of a very popular and somewhat family-friendly restaurant in the very same neighborhood. Yes, both of my kids have eaten there.

So, obviously, I'm not here to take down Ms. Piallat.  I totally feel her pain. I mean, I lived in Berkeley for many years.  That place is like a haven for tiny Kasper Hausers with the parents looking deep into their home brews or bong water while the kids take over Chez Panisse with their mothers' knitting needles.  I did however, make a call to a local radio program when talk of this incident turned into a full on take-down of children in San Francisco.  I felt that this truly pointed to the larger problem of a growing intolerance toward children in this city, or perhaps in the culture at large.  (Though, I really can't say with any authority, as I have lived in the Bay Area for twenty years now.)  But it is true that there is a real disdain for children in many parts of this city.  Not just restaurants, but museums, parks, markets and certain districts altogether.  When I pointed this out to the public radio listeners, someone responded to me with the following comment:

SF is an adult city for adults.  Only ten percent of SF's population are in elementary schools.  Per SF Unified [School District], of children born in San Francisco, one-fourth will leave before they reach Kindergarten age.  Half will enroll in public school.  Of these, 13% will leave before eighth grade.  

Funny, this somehow doesn't seem to me like some sort of boon for the city of San Francisco. Also, just for a quick history lesson for my statically-rich friend: it is also a city of urban renewal movements in which historically black communities (read: families and their children), like the Western Addition and The Fillmore, were totally displaced.  This movement by landowners and developers is not so different from that occurring today in traditionally ethnic communities like The Mission District.  So, yes, San Francisco is moving toward becoming an "adult city for adults" but the cost is very, very high.

It is well-known in this area that there is a flight of families from the city to the suburbs because it is unwelcoming in its prohibitive cost, its poor public school system and its inhospitable position toward children, particularly those in poor and 'minority' families. That is making the city "older, whiter and richer".  It's like Hamlin.  All of the children are led out of this city before they can cause any trouble. Doesn't that strike anyone as both sad an ironic?  That we displace children so that we can have a little peace?  Would we like for those children to grow up without all of the culture, art, history and beauty that this city has to offer? Once the children and their families are gone, isn't the city less culturally rich?  We would rather that children grow up in the suburbs without the influence that we, as city dwellers, could exercise?  I mean, as urban adults, we have a lot to offer.

And so do the the children.

In the end, I found the argument that followed the Zazie incident very disappointing.  The moral tone about the right kind of child and the right kind of parent feels very heavy handed (and very, very dominated by the elite, upper middle class in this once-diverse city -- myself included.)

I have been raising two children in this city for fifteen years and it is still a very difficult place to feel welcome as a family, no matter the behavior of the parent or the child.  We have navigated the very treacherous public school system and put our hearts, souls and wallets into its arts and music programs. And we have the time, the energy and the resources to do that.  Many life-long San Francisco residents do not.

Parenting is a difficult transition under any circumstance, but it really helps to have a community that makes you feel welcome and tells your children that they are valued and loved.

At least as much as the dogs.

...So Rudely Placed

Well, what do you know?  A big thanks you to a super-friend who reads the blog and passed along a recent reference to this research article entitled  "The Impact of Rudeness on Medical Team Performance: A Randomized Trial".  Or, if you don't read research articles, here is the referential article from New York Magazine.

In short, the research supports my premise from the post entitled "There's A Hole in the Sky" that aggressive behaviors between health care providers can negatively affect health outcomes.  This study, published in the September issues of Pediatrics, assessed 24 NICU teams during a simulation involving a preterm infant with a seriously deteriorating condition.  During the simulation, half of the teams were exposed to rudeness by a third party provider and half were not.  Blind judging of performance and decision making determined a 12% variance in diagnostic and procedural outcomes for those exposed to rudeness.  

Don't think that's particularly significant?  Statistically speaking it is.  In fact, that is almost 3 of the 24 cases where mistakes were made.  Now isn't that something? Especially when you imagine 3 in 24 preterm infants with rapidly deteriorating conditions being treated by teams whose communication is so impacted by this kind of mistreatment that procedures and diagnoses fail. Tragic.  

Oh, the Milk Train Used to Rumble My Shack

A troubling pattern in obstetrics is the absolute insistence on exclusive breastfeeding for every woman and her child.  And I don't have to say too much about it, because Courtney Jung did so very nicely in her NYT piece entitled Overselling Breast-Feeding.  

From my own perspective as a women's health provider, I would put far more emphasis on the cultural and social norms that we often overlook when insisting on breast exclusivity, and specifically what it means to be young and/or poor and/or the victim of some sort of sexual violence and how this insistence negatively affects those women long-term, specifically in relationship to their children.

Let's support women to be mothers rather than enforce moral positions about what we expect of womanhood and motherhood.    

There's a Hole in the Sky

Nursing education dedicates a great deal of time to scaring nurses to death.   There are two ways that this is accomplished.  The first is to show innumerable films, provide massive amounts of literature and invite endless speakers to discuss the endemic problem of medical error.  The Josie King story was presented to my graduate cohort twice and it was presented once again when I began my current job. Rightfully so.  Medical errors kill 44 thousand people every year in the U.S. alone. Consider, by comparison, that 347 people died last year from drowning, 10,000 in drunk driving accidents, and 23,000 from drug overdose.  Add those up and it still doesn't number those lives lost to preventable medical error.  

The second scare tactic in nursing education is to "prepare" student nurses for inevitable hazing by doctors and senior nurses in the workplace.   This horizontal and lateral violence is described very matter-of-factly, as a sort of ritual for becoming a good and seasoned nurse, as if we were about to rush a fraternity, but without any choice in the matter - or a sweatshirt to wear after its all over. Perhaps that is because it isn't ever over.  

After having experienced this abuse first hand, and having witnessed a fair number of medical errors in my seven short years as a nurse, how is it, I wonder, that these two issues have never been discussed in tandem, as directly correlated, one to the other?   

This all came to me just last week when I was working with a particularly difficult provider.  She not only undermined my skill as a nurse, but resorted to nuanced, but embarrassing, condescending and personal attacks.  This was in the room of a patient and her family.  Because it went on for the good part of an hour during a particularly long procedure, I had the time to reflect on how I would deal with the situation out of the company of the patient, in a forward but politic manner.  My decision, in the end, was not to address it at all.  This is what we are taught:  ignore this unnecessary and inappropriate exercise of power, or lash out to "gain respect" from those providers who are notoriously abusive.  The latter is a widely accepted social mechanism within the culture of medicine that is, to my eye, sophomoric.  It would be ludicrous in any profession to retaliate, but particularly shameful in medicine where peoples' lives are at stake and promoting anything but cooperation among caregivers is an utter absurdity.  

During my own recent incident, I became acutely aware of the effect that the shaming - or to call it out as what it truly is, the bullying - was having on my physical and emotional state and my critical mental processes. I pride myself in being pretty cool, calm and collected in medical emergencies and being a critical thinker under virtually all circumstances.  Both of those assets seemed to totally dissipate with each abusive remark and, instead of  thinking about the work at hand, I became aware of a number of physical and mental changes: 

• I felt hot and sweaty.  I felt flushed. My skin was prickly and my heart was beating hard and fast. That is to say, I was aware of my heartbeat and breathing which any healthcare provider will tell you is not normal. 
• I was having trouble making decisions and responding to requests, directions and questions from other people in the room.   I didn't feel that I was "tracking" well and found it difficult to make decisions and to move as quickly as I typically do while performing tasks that require full concentration: administering medications, changing IVs, attending to the patient, using the EMR, setting up instruments, lights, taking/transcribing verbal orders, etc. for the provider, supporting my patient and her family.  I was basically finding it impossible to multi-task because I was so focused on not responding to the bullying.  The single task to which I was attuned was my dynamic with the provider.  

This is essentially the worst position to find yourself in as a nurse, because you are running an extraordinarily high risk of making a mistake.  Had I not been in my then-current-but-atypical self-possessed state-of-mind, I would have reacted and responded without much self reflection, almost immediately, which is a terrible approach.  It is the absolute wrong thing to do because the patient then has two providers operating in the same reactionary way toward one another and their actions and thought processes are totally unrelated to patient care. 

According to an American Nurses Association study, 56.9% of nurses report having been threatened or experienced verbal abuse at work.  48% report "strong verbal abuse" on a regular basis. Physiologically, the reaction to stress is embodied in such a way as to make goal-directed decision making impossible. Studies have shown that plasma levels of glucocorticoids and catecholamines increase, causing "increased cardiac output, skeletal muscle blood flow, sodium retention, reduced intestinal motility, cutaneous vasoconstriction, broncho-dilation and behavioral activation" while insulin drops, leading to stress related hypogylcemia, which essentially explains all of the physiological symptoms I had in the interaction with my provider.  Furthermore, when this happens there is an imbalance in hormone levels that can also produce functional neurological changes causing us to resort to habitual coping mechanisms rather than higher level decision-making strategies.  If I were a patient or family member, I would never want a nurse or doctor with inhibited decision-making processes providing care. 

The last thing healthcare providers need in our already chronically stressful work environment is a social and communicative structure that normalizes institutionalized abuse leading to even more stress. The question is how to go about breaking the cycle of power and the incessant bullying that goes on in these work environments.

For once, I think I have nothing to say on this matter: no solutions, no recommendations, no ideas. And the reason being is that the bad interactions that I have had in the last few weeks have been so demeaning and demoralizing that all I can do is replay them.  This does not mediate the unhealthy dynamic nor diminish the power of the shame.  In order to dedicate oneself to the mindful intention of living a good, meaningful and quiet life - and being an effective healthcare provider -  it seems impossible to carry these incidents long enough to come up with a logical solution.

Basically, in penning this post, I have demonstrated that this kind of abuse immobilizes us all - even those, like myself, who virtually always have something to say.  It paralyzes those trying to do right by others as much of the time as possible, those seeking peace in their everyday lives, and those who we inherently expect to protect and preserve the lives of others.  

How can that be? How can we let it be?  

But Always a Woman

Don't look at the #justanurse hashtag.  Don't do it.

Okay, so you did it.  Regrettably, so did I.  And yes, I watched both the Kelley Johnson monologue as well as the play-by-play commentary on The View.  Proud to say a couple of firsts - both for the talk show and the pageant.

So, anyway,  let's have a conversation here, nurses, because the reactions to this thoughtless and, yes, purely sexist response are, for the most part, not helping matters.
For example:



Here are some of the above reactions (those which aren't shameless selfies) in words:

"Nurses be like, that bitch said what?"
"One does not simply insult a nurse and get away with it"
Man in drag cocking handgun: "Nurses be like.. say Dr's stethoscope again"
"I'm more than smart enough to be a doctor but I choose to be a nurse." 

And, finally, while there is so much more to make your heart heavy,  please tell me what healthcare provider - what nurse -  took this photograph, in a medical setting, and deemed it appropriate (an not a humongous HIPAA violation, not to mention seriously ethically repugnant) to post to social media - specifically, for the sake of some inane argument about whether or not nurses use stethoscopes. Wildly, wildly inappropriate and - along with the other examples above - some of the likely reasons nurses are disrespected in the media and, more troubling, in the workplace.

So, what's the problem here?  I'm not even going go to the trouble of mentioning that this started with the Miss America Pageant.  Because didn't we protest this outdated and, frankly hilariously ugly step-sister to real life sexual politics, in like 1969?  And we are talking about  - and defending it as a legitimate forum for professional women - why?

But this being CircusNurse, let's talk for just a minute or two about nursing.  And let's talk about how is it that you would like your profession to be represented.  As better than doctors?  As charity? As a profession of martyrs?  As tough?  As kind?  As a profession of women with a few nice men thrown in for good measure? (These are by no means my ideas; they have been repeated in spades over the past two days.)

First of all, let's stop with the feigned machismo.  Nursing is a profession, meaning that we are supposed to be professional.  This does not mean wearing tee-shirts exalting how we are here to "save your ass, not kiss it" or proclaiming that one should "Be kind to nurses. We keep doctors from accidentally killing you."  This nonsense needs to stop.  Particularly if we want to be taken seriously in the field of medicine.

Secondly, nurses are not doctors.  And our general education and ability to accept the fates and circumstances of other people  - without exerting power - is quite poor, or at least suspect, much of the time.  But I discuss that, at length, here.

Finally, nursing is not about being a saint.  It is not about charity.  My husband and I were just having this conversation last night: once something is deemed charitable, it becomes an inherent exercise of power. Nursing, at its very best, and, frankly, at its very worst, should be about bearing witness.  It is not our place as nurses to co-opt another person's experience, but to be a testament to it.  As healthcare providers, we, hopefully, extend our kindest and strongest professional hands and minds to guide patients though difficult times.  And we witness the joys and sorrows therein.  But we should never mistake this experience for our own.  Many nurses will disagree with me here.

I think there is a really difficult truth attached to the identity of nurses that was illustrated by the monologue which generated this whole debate: once caregiving becomes an interpersonal exercise and identity, we abandon the professional role and we can no longer fairly provide our patients with appropriate guidance.  Many nurses pride themselves in the feelings of nursing, the feeling of being a nurse -  but feelings become a very slippery slope when they can't be separated from one's identity and politics.  We have to stop and ask ourselves, what is behind casting ourselves in a specific light? What is hidden beneath our self-proclaimed altruism?  I have never heard a person who truly provides care for and is compassionate toward other people discuss that care in a self referential manner: that is what makes it selfless. Being a nurse should never be about what one is - or what one is not - in relationship to our patients.

This "just a nurse" rhetoric - which has been around for years and is not actually a clever creation of Ms. Johnson - is a detractor and a way to prioritize the experience of the caregiver over that of the patient.  Listen to that monologue again with this in mind and tell me if is is about the experience of the Alzheimer's patient in this nurse's care or the nurse and her identity.  Now listen to it yet again and convince me that her retelling of the story in that particular forum is not about her politics. Finally, sit back and think about it for a few minutes and offer to me any part of her story that feels like it serves the patient and his family in any meaningful way.    

But, I digress.  Back to square one.

This is all actually about the image of the nurse in American society, right? No.  It really isn't.  Even though I've stood so tall on my soapbox for these many paragraphs, I take my thesis back.  It is actually about the role and the image of women in our society.  And, as usual, we are called out in a sexualized and objectifying forum as not being woman enough.  And we are, yet again, called out... by other women.

Hasn't anyone else grown tired of this yet?

The Little Dog Came From You

Yeah, I admit it.  Calling your dog your child is pretty irritating to me.  I hate to be one of those parents, but I am. (For the record, I was that kind of person before I was a parent.) I grew up around lots and lots of animals and we called them pets, or cattle or fowl or the horses - what have you; we didn't call them people.  But that is beside the point, really.

I have been struggling to figure out how to respond when someone likens their "son" (dog) to my "son" (not dog) as in: "My son (dog) got me up in the middle of the night last night to pee!" My son (not dog)  got me up in the middle of the night, too: for a wet diaper, and to nurse and then to be put back to sleep. And my other son (not dog) kept me up the first half of the night, I terrified, because he is a teenager and well, that is life with a teenager (not dog). "Can you believe these children?" (your dog/ my not dog). No, I can't. These children, humans, little souls, astound me every day.

I mean, I appreciate the sentiment and the love, so I don't want to be inhumane to the 'animal people'. So, I mentioned it to a friend. What to do?  How do I hide my disdain?  How can I be more open and tolerant and appreciative of this boarding-on-disordered-personality* doglove?

I thought she hadn't heard me until later when she said, "Hey! I took my animals to the Santa Cruz beach boardwalk this weekend.  Want to see a picture of them on the roller coaster?"  Best response ever.

*Cluster A: Odd or eccentric behavior / Cluster B: Dramatic, emotional or erratic behavior / Cluster C: Anxious behavior.  See? 

How About a Thank You

John Stewart: Patron Saint of Liberal Smugness   

This pretty much sums up perfectly my longtime feelings about Jon Stewart and most self-described liberals that I run across these days - which is fairly often, this being the Bay Area and all.

"Many liberals, but not conservatives, believe there is an important asymmetry in American politics. These liberals believe that people on opposite sides of the ideological spectrum are fundamentally different. Specifically, they believe that liberals are much more open to change than conservatives, more tolerant of differences, more motivated by the public good and, maybe most of all, smarter and better informed....And Mr. Stewart, who signed off from “The Daily Show” on Thursday, was more qualified than anybody to puncture this particular pretension. He trained his liberal-leaning audience to mock hypocrisy, incoherence and stupidity, and could have nudged them to see the planks in their own eyes, too. Instead, he cultivated their intellectual smugness by personifying it."   

Follow the above link for this very thoughtful piece from the NY Times.

And while we are on the topic, particularly in light of Stewart's take on race and violence and his call to face our "depraved" racial history, I think it is important point out how truly fatiguing it is to listen to people whose superiority on issues is at odds with their actions*. A particular cringe-worthy expression, which one hears all too often in certain circles, is the claim "I don't see race".  Oh really? Because that kind of makes you sound racist. Sorry. There is a lot you are not seeing if you don't see race.  Especially as a white person. I suspect that this is where Stewart was coming from in this much publicized problem with Wyatt Cenac. We all, as white - specifically liberal - Americans are at a risk of  this very same thing: of not recognizing our capital and power and, if criticized and defensive, we are at an even higher risk of revealing what lies beneath.

So in light of The Times piece, isn't it just a simple truth that self reflection requires some real generosity toward whomever is on the other side? This remains the problem I have with Stewart and his legions of fans:  detractors, whether they are conservatives, opposing network talking heads or peers and colleagues who disagree with your position, cannot simply be dismissed as stupid, sensitive, cultureless and oblivious. You have to understand the perspective of other people in order to truly understand yourself and the impact you are making on the world - even if, like Stewart, you claim it is not your job.  Particularly as a public figure, even if satire is your game, it should be a weight that you carry, knowing that what you are putting out into the world - even if it is fake news, or "perspective" news -  may be is the primary source of influence for many, many people.  It is your job, perhaps more than anyone else's, because it is like parenting, where your actions and words completely and totally inform those who aspire to be like you... whether you like it or not.

*If you listen to this full clip entitled "Stewart Eviscerates Stewart", it fits perfectly with Alexander's critique of Stewart's self-effacing yet aggrandizing approach that tends to mock his detractors rather than offer any real self reflection or demonstrate to his audience how to be even the least bit contrite.  

Ghosts and Empties

Thank you, New Yorker, this is something else. 

We Are Not Makers Of History, We Are Made By History

It never fails to surprise - strike that - shock me how healthcare providers talk about patients.  For a long time I thought it was the result of intolerance -  religious, ethnic, cultural, economic - or doctors and nurses feeling superior to and wanting to control the behaviors and experiences of patients. However, the more I truly listen to what providers are saying to patients, and, perhaps more telling, to one another, the more I realize that it is fundamentally about a lack of historical understanding.  How are we situated in this particular cultural and historic moment and what has come before that has informed our current consciousness?  I have lamented here many times that I am struck by our very poor historical memory.   I have come to realize this is not the issue at all, for how can one remember something that was never learned?

Recently, I have begun to think about how both medical and nursing training are sorely lacking in any basic, general education.  Bizarre, I know.  How could we not be educating the professionals whose sole purpose it is to understand people, not only by way of the body, but through culture, day-to-day lived experience, family, work, etc?  How can an educational system train providers to diagnose without teaching them to situate absolutely every situation presented in history? Why do doctors and nurses speak with such confidence and attitude in regard to their own judgement of patients, but often lack any real understanding of the historical experience that has informed a patient's entire existence?  

Undergraduate study in the United States is, to my eye, a sad reflection of our general society in its total lack of basic education.  As for medical school, it teaches the minutiae of pharmacology, pathophysiology, microbiology, microorganisms, pathogenesis and much more precise practice and knowledge geared toward specialization. Medical students, as a whole, have some grounding through a four year university education in which, during the first two years, they fulfill the basic requirements which probably include things like reading The Yellow Wallpaper or sampling a bit of Aristotle.  Nursing school, on the other hand, is solely focused on systemic education and the making of healthcare providers. And while it may include some cursory ethics and "cultural competence" classes, it totally and completely lacks any rounded general education, even in the simplest form.  

Read Mark Twain? How about James Baldwin? Can you find Uganda on a map? How about Yemen? Can you name a logical fallacy? Can you tell me about Plato's cave?  Have you seen the work of Jacob Lawrence? Can you tell me about the Dawes Act or perhaps Japanese internment or what about American eugenics?  In my experience with both groups, for the most part, the answers are no.

So this lack of historical understanding and educational/ cultural paucity leads us to one place, the place where I end up stuck many times when interacting with healthcare providers.  On an almost daily basis I ask myself: What is it about poor people and procreation that healthcare providers find so intolerable?  I hear said that it has to do with  "dependence upon the system", "skyrocketing healthcare costs" and "inappropriate/ overuse of social services." (Direct quote "I'm all for discouraging the poor from having many children").  I also hear this animosity couched as concern, as in "risks of multiple pregnancies", "poor maternal and fetal outcomes" and "welfare of the children".  These concerns, however relevant, are never discussed in reference to middle class/upper middle class nor, specifically, white families having more than two children.  It is true that it is not the norm, generally speaking, for the upper middle and upper classes to have large families, but it is true of the rural poor and I suspect the same feedback would be found regionally.  That having been said, as you may have gathered or intuited, fertility trends by social status tend to show a decrease in reproductive rates as a group gains higher status.  The simple explanation is that this can, of course, be influenced by education about, and access to, contraception. But there are much more complex social patterns related to education, women in the workforce and the perceived social potential of a childfree lifestyle.  Additionally we would have to consider the historical trend toward more children in the lower classes as a form of familial support, historically high death rates and, of course, the growing gap between the rich and the poor. If you want to take the evolutionary biology perspective you could argue that this is simply the result of growing up in a "harsh, unpredictable environment... where you might die young [and therefore requires] a fast reproductive strategy - grow up quickly, and have offspring early and close together." Interestingly, the desire to attain a higher social status has a direct correlation to the decrease in fertility among individuals; research indicates, however, that maintaining one's social status does not necessarily have this same attributable effect on decreased procreation.

So what about being in healthcare has this influence upon perception of other people's fertility and personal life choices?  I heard recently a woman who had three children at 24 years-old referred to, with absolutely no irony, as a "repeat offender".  There will be audible "tsks" if a woman is a gravita in the double digits, regardless of the number of children she has borne and without consideration of the number of losses whether terminated pregnancies or spontaneous abortions, because we have no access to this information unless we are a clinician providing direct care.  Not that these numbers should matter in our treatment of the patient for her current pregnancy.  The most recent untoward discussion to which I was privy was in regard to mandatory hormonal contraception upon discharge from a hospital or birth center for women of lower SES after delivery of the third+ child.  I should say here that this discussion did not take place in the institution where I was educated nor where I work, nor was it presented as a recommendation (though one of the providers did claim that it was a standard practice in a medical center in which s/he had worked several years prior).  The idea was being tossed about more as an illustration of how one might control behavior via procreative limitation: specifically, controlling the behavior of people who just happen to be poor and largely from minority groups.  When I called the plan out as dangerous in terms of its ignorance of our history of eugenics, I was quickly rebuffed with the response that it was simply "making free birth control available to the poor."

So you can call it paternalistic or call it an effort to "save people from themselves" (more common hyperbole) but if you're going to call it anything, you'd better also include calling it a contemporary branch of the eugenics movement and way to control behaviors that we find repugnant.   Namely all of the behaviors associated with being poor. And if you want to do something about it, start with a history book and a bit of mercy.  

Blindlessness

For your viewing/listening pleasure.

You're welcome.

"I don't think we did go blind, I think we are blind, blind people seeing, blind people who can see but do not see." 
- José Saramago, Blindness

Raise Up, Baby, Get Your Big Leg Offa Mine*

Sphinx #2, From The Full Body Project by Leonard Nimoy

An important piece appeared in the NYT Science Times yesterday discussing weight and bullying. I wanted to share it here because of some significant, if nuanced, facts that arose toward the end of the article. Specific to healthcare and the way in which patients are treated in the medical setting, it seems advantageous to both parties, understanding how body size does not necessarily reflect any measurable health outcomes nor tractable patient behavior.  I have reflected here before on the use of BMI as an outdated standardized measurement of health and lifestyle and have lamented that it seems particularly problematic when assigned as a health marker in my field of obstetrics.  Here is the bit from the NYT article that is taken from a 2014 CDC report:

"A study of more than 400 doctors found that one in three listed obesity as a condition they responded negatively to, ranking it just behind drug addiction, mental illness and alcoholism."  What's more, "while some healthcare experts acknowledge that individual genetic and metabolic differences mean that some people are more prone to gain weight than others, the most widely disseminated public health message is that anyone can achieve a desirable weight by eating less and exercising regularly."

Drug addiction, mental illness, alcoholism, obesity: I think we can agree that these are all very sensitive issues among healthcare providers. I would include pain and poverty in the list of things that can send doctors and nurses into a tailspin. (Is the patient rating her pain an "8" while she talks on the telephone or eats a hamburger and does that make you angry?  Do you sound off to your colleagues when a patient takes an ambulance to the hospital for nothing other than early labor, or a twisted ankle, perhaps because she has no transportation and lives in a dangerous part of town? Then you have experienced the problem, maybe without even knowing it.)

My suspicion is that these issues reflect one simple, unifying vexation of the healthcare provider. That, quite simply, is control.  Whether grounded in a belief that the patient has no self control, no pain control, no control of the everyday necessities of living, or of the provider's desire or need to exert control, it seems that patient experience (which some may label "behaviors") and differential existence (as in, different from our own) are something that we need to learn to incorporate in a more inclusive and open way.

Perhaps an interesting reflection point for us all the next time we have a patient who is just simply rubbing us the wrong way: "Is it the patient... or is it me?"

   *From Big Leg Blues, by the amazing and inimitable Mississippi John Hurt