Boundaries and Patient Care

I don’t usually turn on my phone or computer before 7 am, but today I wasn’t sure if we would have a meeting to discuss grant writing with one of my patients who has a program for young women. She hadn’t replied by the time I powered down my computer 11, after a late-night zoom meeting for my work in California. Sleeping until 6:30 is a new and exciting development for me, and I owe it partly to my dogs who ate our neighbor’s rooster when it jumped into our yard last week (turns out, this is culturally acceptable if it happens in your yard). I never knew how quiet mornings could be without that one rooster.

So I turn on my phone and I see that one friend messaged me at 4:30 am because they were feeling sick. They wanted to be seen right away, but I was planning to work from home during the morning and see patients in the afternoon. I advised my friend about a home COVID test and offered to see him in the afternoon. At 7:30 another friend messaged me, one who doesn’t usually mix medical concerns with messages, but we are in the middle of a cholera epidemic and she was starting to have symptoms, so she needed to know what to do. We don’t have tests for cholera and symptoms can worsen quickly, so I advised about oral rehydration and offered to see her if she came in during the afternoon. Then I finally checked my messages and the other patient wanted to meet by zoom at 8:30, but it was already 8:00, so I told her we would need to schedule further in advance in the future. There were patients emailing me about forms to complete and tests to follow up and another wanting an appointment who couldn’t get through to the front desk. I tried calling a few times, too. I also couldn’t get through to the front desk to book.

These days, I only let the front desk book afternoon appointments from 1:30 to 3:30. That way, if someone contacts me to be seen directly, I can confidently tell them that I am free at 1:00 or 4:00. It also means that I have less empty appointments in the middle of the afternoon with more people taking early and late appointments. So it is nice that I can know when to show up and not have people waiting for me, or come in early only to find that nobody booked an early spot. But it also means that, on days when I only have 5 appointments in an afternoon, my clinic days can be as short as 4 hours. This is a huge change for me, because it means that I can get an entire half-day of work in before clinic (or after if I am taking calls in the US). Overall, I have reduced the time I spent in clinic in 2021 and 2022, though I am still seeing more patients than the two years before that. These days, I usually help twice as many patients virtually, through email or phone calls, than I see in clinic. I guess that is good for a preventive medicine doctor, keeping patients out of the clinic if they don’t have to come in, but I still have to work on boundaries to make sure that I’m taking time off when I need to.

Celebrating Miracles with Patients

It’s been a while since one of my patients has made such a quick and miraculous recovery. To be fair, it’s been a while since I’ve cared for patients at all, since I was in the US for 14 weeks and then I was sick for an extra week soon after getting back. But I met this 58-year old last week. His brother, a local academician, scheduled him for a visit with me while he was in town for the holidays. He had a stroke a couple years ago and has struggled with high blood pressure ever since. Even though he was on three blood pressure medications and attending the most specialized blood pressure clinic in the country, his pressure was always high and now the family was concerned about confusion and deterioration as well.

He was the type of patient who got my own blood pressure a bit higher. At 196/118, it seemed like a matter of time until he had his next stroke. To be honest, I was concerned that he had irreversible kidney disease – I haven’t often seen pressures that high which didn’t either cause or come from damaged kidneys. But last week we praised God when the kidney tests came back normal. That meant that I had a lot more freedom in the doses of medication he could take, and a lot more hope that the medications could help. Last week we thanked God that the tests looked relatively normal, and then we prayed for miraculous healing, of both blood pressure and confusion. And he had been on my heart and in my mind and prayers for the following week. I called his brother just yesterday to make sure he would come back for his appointment. I didn’t want to waste any time when every day at that blood pressure could mean another stroke.

But this week we saw a miracle. All I did was change one short-acting medication to a longer acting blood pressure medication in the same class, and I handed the brother some information about lifestyle – about reducing salt and increasing vegetables. Even during the Christmas holidays, the family ensured that meals were healthier. His brother walked with him every day. And I couldn’t believe his blood pressure today. Studies show that one blood pressure medication can be expected to improve blood pressure by about 10 points. But this patient had an improvement of 94 points – ten times the expected benefit. I had to double check his pressure in my office myself. It was 138/82. I couldn’t have imagined anything better. I asked him a couple times if he had side effects – most people who have such a dramatic drop in pressure will have headache or dizziness even as they come into the normal range. But he was fine. In fact, he was feeling stronger and his brother said that his confusion was even improving.

The family tried to act like the improvements were due to my own professional capabilities, but I had to set them straight, I knew what the science showed and just how little my medications and my advice could do. A miraculous turnaround deserves a prayer of thanksgiving to God. So we prayed this time a prayer of celebration, giving thanks where thanks were due. And I affirmed the family, they had done such a good job supporting their family member.

I’m so blessed to have an inordinate number of miracle patients. I admit, wanting to see miracles was one of the reasons I wanted to practice in missions in the first place. It’s a blessing to journey with patients and celebrate with them. Some see their blood pressure or blood sugar drop by half in a week. Others go from severest depression to the mildest symptoms in two years. Some I continue to pray for, never knowing if that first difficult consultation will be our last. These days, I do spend more and more time working to try to improve systems and plan programs and help communities. But I can’t imagine ever not seeing patients, being part of their story of how God brings healing in ways both miraculous and ordinary.

Sabbath before New Year’s Day

The neighborhood roosters woke me up before 6, but I was well rested because I got myself to bed on time last night. The morning is beautiful, I love to walk around our yard when the sun has just risen. I turn on our lovely porch fountain and bring some rainwater from the bucket to fill it up a bit more. We have power today so I am able to heat some oats in the microwave and use my kettle for tea. I whip up some matcha and sip it under the grape arbor. I count 27 roses blooming and I know that there are even more than that in the back yard, such beautiful colors and delightful smells. I eat a Christmas cookie with my bitter matcha, loving the way that the ginger compliments the tea.

I eat my oats with some fancy mixed nuts, we still have some left from our last trip to the US, but I mix them with local macadamia nuts so that they last longer. I decide to brew a red oolong, one of my favorites in the past. I take some deep breaths during the steep time – I decided that I can get more time in for deep breathing and meditation if I apply my tea steeping time. Just like I decided I should pray while brushing my hair. I love that my hair is longer than its ever been, but with the humid climate, water pressure issues, and my frequent runs and core workouts, it gets a bit tangled. So last night I got a nice 9 minutes of uninterrupted prayer time, untangling my locks and my thoughts about the year.

Today the red oolong is dizzyingly delicious, with notes of sweet honey, fragrant flowers, and mineral depth. I am so thankful that I can taste again, just two weeks ago my COVID-induced anosmia prevented me from even noticing salt. I take my tea back to the office for some sipping and rebrews. I have a great day planned: reading in the outdoor swing, taking a bubble bath, stretching and doing yoga and maybe some jogging. Lots of tea and lots of reflecting.

I want to read through my notebooks from last year, the goals I set and the “ah-ha” moments from those wellbeing conferences. I want to review the hours I spent working, what I was working on, the patients I’ve seen, the money I’ve spent, and how many days off I took. Last year I didn’t take half of my vacation days. This year, I took that many days off just in December, thanks to the COVID. I’ve had time for painting, reading, exercise, developing professionally, and being outdoors. I wonder where the upcoming new year will take me. I’m hoping I’ll be able to make some progress towards goals while avoiding overwork. It’s way too soon to tell, but I feel good about the start that I’m getting.