Grade Whore

Hi my name is Dr. Laura Katz and I have been a doctor for 24 years. I signed up to care for people 24 hours a day, 7 days a week, regardless of how much I get paid. I signed up for a lifelong commitment to the health of others, sometimes at the sacrifice of my own health and my family life. I signed up to compassionately listen, problem solve, give 110% and guide people every day into better futures for themselves and their infants. I did not sign up to be a grade whore!

OK. That was a strong word, but it is fitting nonetheless. So, what the heck am I talking about? No worries. I am about to explain. We now live in a society in which patients do not seem to be thought of as patients anymore. They are thought of as clients or consumers, which changes the whole flavor and mentality of the doctor patient relationship. ( I personally am kind of stuck on the patients as patients idea. However, I am behind the times to say the least.) I think that this kind of thinking is potentially very harmful. The kind of thinking involved that classifies patients as consumers or clients lets loose a whole wave of entitlement behavior on the part of the patient. The old adage ” The customer/client is always right” has really run amuck here. Patients now think that they should be able to go to their doctor’s office and demand what they want for their medical care or demand what pills they should have prescribed , just like they can demand what hair cut they want or what good they want at a restaurant. If they don’t get what they want, they have complete free reign to go on Google, Health grades, Vitals and attempt to destroy that doctor’s reputation with little to no recourse available on the part of the physician. Sure, we can go to Google and attempt to reply or prove why the stated comments are skewed or not factual, but the chances of that review coming down are slim to none in my experience. What’s worse, said patient who is posting the bad review does not have to really be accountable for it or even prove that they have ever actually been to that doctor’s office! What?! How is that ok? How did this review process get so out of hand? I am all for having input in your medical care and having patients advocate for themselves and insist on quality, but these rampant reviews when things do not go their way? No. I think that is wrong. Reviewing the wrong doctor? This could actually ruin someone’s career. I have had some reviews in the past that were awful and caused anguish and concern, only to find out after extensive research that that person had never actually seen me! I am sure that they are still out there somewhere and they still haunt me. I never want anyone to be hurt or wronged by me, but I cannot help rectify a problem with someone that I have never met. Still, these reviews are treated as gospel by those patients who carefully comb through online resources when selecting a doctor. They may not stop to question whether they could actually be true or not. They will just keep looking. I have to admit, as a patient, I look for reviews as well when selecting a physician, but if I can speak to someone directly who has seen the physician, that holds a lot more weight in my decision-making process. I am much more a fan of fact, not potential fiction.

We are all obsessed with reviews even at a hospital-wide level. We have things like HCAHPS and Press Ganey reviews that survey patients in a whole hospital environment. Hospitals then turn around and use these reviews to grade themselves and physicians and somehow use them as a judgement of worth. Now I will admit that these reviews at least require some documentation that a patient actually received care at that institution, but there are still too many factors not under the physician’s control that they are being lumped together and used to judge them. Patient’s will return a poorly rated survey if they didn’t like their hospital food or if they did not like their nurse for example. These are things that the doctor does not have any control over. There are some patients that you can bend over backwards and sideways for and they still will not be satisfied. Are you supposed to go against your medical judgement to do something that a patient wants in the hope of a better survey score? This is not supposed to be some sort of contest in which the 5 out of 5 score is the only objective. Did you know that places like John’s Hopkins have done studies regarding this kind of patient/consumer driven care and that outcomes tended to be worse when patients dictated their own care and doctors complied for fear of a bad review? Think about that.

This kind of culture sends us doctors scurrying and begging for positive reviews from our patients in the office as well on a daily basis because now we are worried what could be out there on all the public sites and how many of them could potentially apply to us. I have to admit, I have stopped looking at those reviews because they really mess with my head at times and actually get in the way of me providing quality care to my patients. I understand the concept of healthy feedback and its potential utilization in betterment of myself and my practice, but that does not seem to be the intent of the review process as we know it today. It feels like I am begging for a good grade or asking patient’s to sign some invisible report card when it really does not matter. I will give them 110% whether they leave me a review or not. Now having said that, we do conduct in-house reviews every day. Every single patient is given an option to review our practice and myself every single day. Every single patient decides whether or not they want their review to be shared. Now these reviews I look at carefully, each and every one. I take these to heart because I know that these are the patients that I am actively taking care of. We have been very lucky in that this review process has been very informative and that patients have been very thoughtful in their reviews. This has allowed our practice to take all appropriate action when necessary. I do believe in the review process, but it has to be done the right way to be constructive and true to it’s original intent.

I think that our culture of the patient as the consumer has also led to a huge breakdown in the respect that patient’s show to their physicians. No, I am not yearning for patriarchal 1950s medicine when gruff physicians dictated to their patients and patients followed without question. But, there is a part of me that thinks it is worse to have patients running amuck and dictating their own care. The customer/patient is not always right in these situations. Sometimes patients want things that are actually dangerous for them and would put both of us in danger. I actually have the medical degree and the training. Please let me use it and guide you. I like patients to be on their own team. I like to make decisions together. I like them to advocate for themselves, but not yell at me when I don’t do what they want even if it would be bad for them. I think we need to compromise somewhere in the middle. Have a fantastic day everyone!

Dr. Katz

What happened to my sweet girl?

I think it is safe to say that most every mom is asking this question when her daughter hits the teenage years. I find myself asking that like all the time. I can remember the sweet, fearless, loving, carefree, friendly to everyone child who lit up every room that she entered. She was pure sunshine, almost never cried and almost never stopped chattering away telling me about every moment of every day. She was brilliant and not afraid to show off. She was full of infinite talent and every day was a new adventure. I couldn’t wait to see what she would do next. I wanted her to stay little forever. I was sure that our bond would last forever! I felt so connected to her that sometimes I felt like I could actually read her mind. Ok I realize that this all sounds like a huge wad of rose-colored glasses baloney, but I definitely wore them with pride. Every mom does at one point or another.

Boy how times have changed! Guess what I am doing right now? My little ray of sunshine has me watching Annabelle Comes Home because she loves horror movies and sometimes they are the only thing that can brighten her ever dark or at least mysterious mood. ( I have to admit that I am not exactly under duress because I love them too) But seriously, we have gone from My Little Pony to Annabelle? Overnight? Just kidding. It is not really over night. I realize that if I don’t sit and watch it with her, the end result may be that she just disappears up into her room until it is time to go to bed and then I will be left all by myself. At least this is some kind of bond right? It’s not the tons of cuddles and snuggles that I might prefer, but it is something. Sometimes you take what you can get.

I can tell ya that the chatterbox I once knew has also gone the way of the dodo. Most days there are sullen stares and monosyllabic utterings at best, complete with a complimentary sullen look or two. It’s not that she it outright mean or unkind, just enigmatic and reluctant to communicate without pulling so many teeth that you are afraid you will run out…lol Every now and then she throws me a bone and we have an extended conversation and I get a glimpse into her beautiful head and what she is thinking, but these moments are too few and far between for me. I soak them up like a sponge while trying not to seem too eager.

The fearlessness has disappeared, which makes me sad. I miss the little girl that could just charge up to anyone and make friends within minutes. Now she hesitates, overthinks, and sometimes misses out on some really great opportunities and friendships. I don’t completely understand why. She labels herself as having social anxiety as an explanation. She worries about looking like she is trying to suck up to people and that somehow she will get interpreted as being disingenuous in some way. She seems to need a lot of convincing that people will think she is worth knowing in some situations. I find myself wondering how this happened? I realize that it is part of the normal course of growing up to tailor behavior dependent on the situation and that people would not always find it appropriate for a teenager to just go running up to people whenever she wants. Ok, sure, but how did it get so far? How did I miss this progression from social adjustment of age-appropriate behavior to outright anxiety? It wasn’t for lack of asking her how she was doing or trying to “check-in” with her on a regular basis. Did something happen to her? Did someone hurt her? Is today’s teen social culture so stressful that it turns happy-go-lucky kids into anxious adults? I can imagine that that would be true. Look how open and exposed they are all the time with social media. These kids don’t keep anything to themselves and in turn leave themselves open for all kinds of judgement, rumor and scrutiny. They put more pressure on themselves than we adults ever could. Now there doesn’t seem to be any limits to bullying or anything else. If you want to ruin someone’s life nowadays, you don’t even have to be near them. You can just cyberbully them online. What is happening?

She has a boyfriend now too. He seems great and they have things in common. She loves him. They are both respectful and good kids. I like him. He seems to make her happy and annoyed at the same time. It is a strange combination, but I can understand it because that is how I feel about my husband sometimes…lol For all the good parts to their relationship, the reality is that it creates another level of separation between us. He is probably her number one choice to spend time with now. Now I have to wonder what they are up to. Are they being safe? Are they getting themselves in over their heads? I am no dummy. I know what teenagers are up to these days. I see them every day at the office. I have to realize that my main job now is not to necessarily know what she is up to every minute of every day, but to keep the lines of communication open, hope that she has been listening to the advice that I have taught her, not make it any easier for her to get herself into trouble and above all, hope that she will come to me if she does. That is NOT easy.

Ok in my rational moments, I actually realize that my girl is still my girl. She is still talented, beautiful, intelligent, and wise beyond her years. She still loves us. She is just changing and trying to figure out her new mood-labile hormones, growing up, how to fit into the world in a different way and how to balance her relationship with her boyfriend and her relationship with us. That is a lot of change over a pretty short period of time if you think about it. All these things are just as hard for her as they are for us. There will be no easy path through this. I just have to keep reminding myself of that and try to be patient. Have a fantastic day everyone!

Dr. Katz

Dance Moms- Not for the faint of heart

Yes. Yes. It’s a loaded title. Let me first start off by saying that EVERYTHING I am about to say is my own opinion. It does not necessarily apply to every mom, every kid, or every studio. I also want to be clear that I am talking about the competitive dance world scenario, not the taking recreational class for fun scenario. It is meant to be entertaining and maybe thought- provoking, and that is it. So, plunge ahead with a grain of salt if you please.

Ok, now that we got that out of the way, here goes nothing. So, Dance Moms is a show that a lot of us have seen. We all watch it with a sense of morbid fascination or just plain horror, but we can’t stop watching at the same time. I now I used to sit there watching with a kind of inner chuckle saying ” How ridiculous” to myself and ” This would never happen at our studio.” But then, the smallest of inner voices echoes persistently in the background,” Is this so far-fetched after all?” Then, it’s all over. I find myself analyzing my daughter’s dance situation and checking it for anything particularly toxic, which isn’t in itself a bad thing. ( BTW it’s all good and she is the happiest I have seen her in years with all of the studios she is involved with currently- whew) Then I get to thinking about dance mom life in general and what I have seen, which is not all good. But, I always try to keep in mind that I chose this and I get what I paid for.

Now, once again, I want to remind everybody that I am neither generalizing or referring to any specific situation or child or studio. The following is just some thoughts I have on some things over the years. I think dance is overall a truly amazing sport, yes I said sport, that your child can participate in. It potentially cultivates lifelong friendships, teaches ethics, fitness, sportsmanship and above all, targeted discipline. My child has benefitted from all of these. These components are fantastic! Add to that the fact that this new culture of trophies for participation only does not seem to have caught up to the dance world. That’s fantastic too. Yay! These are the reasons that we all became involved in the first place right?

However, There is a double-edged sword component to the dance world for the child and the parent as well. Along with those positive attributes, there are some negative ones as well. C’mon now, we have all witnessed them, had secret conversations about them, and dwelled on them whether we meant to or not. The first one I have noted is the potential blurring of the motivation line between the parent and the child. What I mean by that is that, for some parents, it becomes more difficult as their child progresses, especially in the competition world, to keep it straight just who their child is dancing for. Is the child dancing for themselves, or for the vicarious pleasure of the parent? When the child wins at competition, are you cheering for them or are you actually cheering for yourself in your own competition against other moms and how their children performed? I am sure this is not true for everybody, or even most moms, but that component is out there. The term healthy competition is not one that I always feel applies to the dance world. I think that the term healthy competition, in it’s purest sense, should mean competing with constructive feedback for the betterment of individual skill. Is that what really happens? Or is it for studio bragging rights? Does competition in this day and age truly foster a team spirit in which each member boosts the other to keep doing better, or does it potentially sever long term relationships over misguided purpose? These risks are things that studio owners and parents need to monitor carefully and hopefully positively guide their young charges to keep in mind the true purpose. I have seen some studios do a fantastic job of this with lots of group bonding and support and I have seen some that don’t. You know the term no child left behind? This was originally used in reference to providing the fullest educational opportunity to every child, regardless of ability. This is a much more difficult thing to offer in the dance world, at least not in the competitive dance world. The plain truth is that your child will be left behind if they are unable to progress in their skills in a particular area. They will not be able to participate in the same small groups if they cannot do what the other children can do. This is not an intentional slight on your child, this is just a consequence of skill level. You as a parent need to be prepared for this possibility and not take it with resentment and project that onto your child. This is just part of the natural course of the competitive dance world. In the end, even with all the practice in the world, if there are certain skills that consistently escape you, there is only so far that you can go. I understand that people teach kids that success is 90% perspiration and 10% skill, but the reality is that that skill component is really the final element that will push the student further. For example, if you can’t master a foutte no matter how hard you try, no professional ballet company is going to give you a pass because you were working hard. They just won’t accept you in.

There are some other things to brace yourself for before entering the competitive dance mom world. First, set aside that 10,000 extra dollars a year aside now…because between comps, costumes, lessons, festivals, therapy sessions( ha ha), that’s about what it runs. You might as well know up front. Also, be prepared to be able to keep a healthy discussion with your child throughout about the real goal of them dancing, whether it is to pursue a career in dance or for recreation and fun. Make sure that you keep tabs on the human lessons that are involved…remaining a good person, realizing that competition is not everything, sportsmanship, maintaining good physical and mental health. Watch over your child and protect them, not in a helicopter or momager way, but in a healthy way. If you see them growing and thriving, keep going. If you see them withdrawing and experiencing mental anguish all the time because of negative feedback or over-focusing on trophies and those ever-coveted convention scholarships, please rethink it. I want to clarify when I say watch over your child that is not always easy. You can’t realistically strive to be in charge of everything without consequences. Your studio owners and teachers are trying to run a business as well and they have to make decisions that they feel are for the betterment of your child and their studio at the same time. It is what they have to do to succeed. If your version of protecting your child consists of constantly complaining that your kid is not center stage, whether they deserve it or not in your mind, almost never goes well and will have unfavorable repercussions for the both of you. It’s just not the best way to go about it. However, I do think that it is ok to not just stand by if you see your child being berated or mercilessly scape-goated. You don’t have to teach them that they must lie down like a rug and take whatever is coming to them. There are reasonable limits. I can honestly say that I have regrets in my past dance mom life regarding not speaking up or acting up more( because I didn’t want to go to jail that But, at the same time, I was struggling in those situations with not teaching my child that it was ok to lower myself to the unreasonable level of the person I was talking with. I should not have to lose myself and what I stand for to retaliate to an untenable situation. Those are the times in which you hopefully have taught your child to be grateful for the training they have received, hold on to the lessons that they have learned, and gracefully exit without burning bridges. That is the goal for me at least.

The last thing I want to address in the competitive dance mom world is what I am going to refer to as the “suck-up fangirl gene.” I just don’t seem to have it. I see moms falling all over themselves to impress and kiss up to dance teachers, desperately hoping that it will result in their kid getting ahead in a studio. I see some studio owners fall for it and I see some dismiss it. I am far more likely to gravitate to the ones that don’t respond. This is why. First of all, I seem to be missing this and I don’t think I would be good at it if I tried. Second, and most important, I want my child to succeed based on her merits, not whatever ass-kissing I am attempting. Trust me, I would only get in her way more because I am really and epically poor at it…..and I am ok with that. Now , having said that, I am guilty of pushing my child to go up and talk to someone when she is hesitating. This is only because I know that her social anxiety is getting the better of her and I also know that she has carefully planned exactly what she wants to say from her heart and is just too afraid to say it because she worries that it will come across as sucking up. That makes me sad. I try to explain to her that her commenting on something that she noticed or admired about someone and expressing it with no agenda is the furthest you can get from sucking up. I am an educator as well and if I had an inspired student come up to me with a comment that shows that they were paying attention, I would be all over that!

Having said all this, I want to be clear that my child is still a dancer. She loves it and plans to do it for the rest of her life. She has learned from people all over the world. She has learned how to be disciplined and accomplish tasks on a timeline. She gets to use both sides of her brain every day. She gets exercise. She gets a kind of emotional, mental, and physical stimulation that she cannot get from anything else. Will she pursue it as a career? Who knows? As long as she is happy, that is really all that matters to me. Have a fantastic day.

Dr. Katz

Brace yourself Effie!

This is literally one of my favorite lines from Mrs. Doubtfire. This is the sentence Mrs. Doubtfire uses to describe her late husband Winston’s idea of foreplay. Nonetheless, she persists that if that was her husband’s approach, she was going to make herself satisfied with it ” to the grave.” Now I get that this is a hypothetical and that Mrs. Doubtfire was really Robin Williams in disguise trying to get the details on his ex-wife’s love life. However, what Mrs. Doubtfire said rings true for a lot of sexual relationships.

There are a lot of women out there not really having as fulfilling a sex life as they could be. They are accepting whatever standard their partner is dictating and just going along with it without complaint, potentially orgasmless and without satisfaction. Why ladies? You don’t have to put yourself through this. You too can have good sex.

I guess the first thing to do is to attempt to understand what good sex means to a woman. Believe it or not, there are a lot of different view points. There are lots of articles and cold scientific papers written about the components of sexual arousal in woman. I find most of these pretty dry for my taste so I decided to take a patient poll instead of real women at my office. Here is what they had to say.

A lot of them said that love and good sex were intertwined. If they were in love with the person or at least had some kind of emotional investment, they were much more likely to think that the sex was satisfying. That seems to be pretty typical of the female psyche. As women, we have a tough time accomplishing anything without any kind of emotional commitment. Even the immortal Samantha Jones in Sex and the City Season 4 had to finally admit that the sex she was having with Richard got more intense when she realized that she loved him.

Most of them said that they did not just spontaneously think of sex at a random time like men do. They needed to be coaxed or experience some kind of foreplay to get interested in the first place, much less experience good sex. They were concerned that that was abnormal. No ladies. It is not. The vast majority of women experience what is called facilitated arousal. We need to be coaxed and petted and kissed to get in the mood to increase our chances of a happy ending. This is NORMAL! We need FOREPLAY! As exciting as it looks in the movies for a woman to be randomly swept up, protesting and then thrust into a sexual act which ends in a tremendous orgasm, this is not reality for most women. Most men could be randomly sitting somewhere and suddenly become erect and be ready to go.

A lot of patients said that the sex was better if the relationship was healthy without trust issues or fighting. They felt like they could relax more and be open to more experiences if they weren’t wondering if the relationship was ok or if their partner was cheating or if they were mad at their partner. I find, on the other hand, that most men could be furious with their partner one minute and be in bed with them the next like nothing ever happened. I think this may be where the somewhat misguided term makeup sex comes from. I am not saying that I have never done it. But I have to be honest, if I am really ticked off at my husband, his penis is the last thing that I am thinking of. Just sayin.

A lot of patients said that they had to be attracted to the person for the sex to be good, or to be able to have sex at all. The crude stereotypical saying that men will “sleep with anything” definitely did not apply to this group. The interesting thing is that they did not just mean physically. They were also referring to mental attraction and emotional attraction. They needed to have some kind of connection with the potential partner to make things work.

Last but not least, there was a group of patients that said that sex was good only if they had an orgasm. Period. Believe it or not, this was the smallest group of patients. Hmm.

So, I guess the bottom line( or lines) is that good sex is in the eye of the beholder. You don’t have to just accept unsatisfying sex. A healthy relationship is key. Men and women are different in this regard and that is ok. Trust is essential. Foreplay is actually very important to most women and not just a waste of time. Well, that’s all for now. Have a fantastic day!

Dr. Katz

All doctors are rich! They are just trying to make money off of me.

Yup. That is what I hear on a daily or at least weekly basis. I have new patients that will come in, fresh off of some bad experience with another physician, and accuse me of trying to order tests or procedures ” just to make money.” I also hear that all doctors are rich no matter what they do. They just get everything that they want. My first and most resounding response to statement like this is a resounding NOT TRUE! At least it is not true for me. Let me clarify a few things from an actual doctor’s perspective.

The first part about all doctors being rich. I can tell for myself that this is definitely not the case. You see, when it comes to monetary wealth, you actually have to have some in order to be considered rich. The average physician has to go through 4 years of medical school and then 3 years plus of a residency and sometimes an additional fellowship after that to finish training in his or her specialty. Keep in mind that medical school loans often tally up to the hundreds of thousands, unless you are one of the lucky few that had help from family etc. Then as you progress into residency and fellowship, those loans become due and the minimalist salary that you are being paid usually won’t cover the loan payments and allow you to actually pay your bills, so you end up deferring them as they steadily accrue interest for years and you ending up owing more than when you started. YAY! Then, you start looking for a job. The current trend nowadays is weighted heavily toward physicians seeking employed positions with hospital, which definitely helps with the past debt because they often offer to repay student loan debt and help with relocating expenses, plus you don’t have to worry about office expenses. For the rest of us rare-breed independent practitioner schleps, we need to come up a couple hundred thousand to start a practice, plus at least 6 months of overhead until the practice starts taking off. in addition to that, it may take about three months before your first check from any patient insurances is going to come in. So now, the debt is up to a solid half a million at least. On top of that, now you deferment of your student and medical school loans is now up and you have to start paying on those. The good news just keeps on coming.

To sum up, once you get to the point where you get to actually start practicing medicine on your own, count on at least a half million dollars in debt. Ok check. Now let’s talk a little bit about the realistic picture regarding what you can make as a doctor. Before we even start, let me be clear that I am not including the famous doctors on TV, high profile owners of regional or national practices or doctors that got to jump into an already well-established solo or group practice. I am talking about the rest of us who are still in solo practice who do everything ourselves. Let’s first deconstruct the idea that doctors just get handed everything. I do not know about other physicians but I did not just get handed anything. I covered my education with loans. I started my practice with loans. I worked hard. i went to school for 16+ years and I still have to attend continuing education conferences and earn online credits and renew my certifications yearly. i am on call 24 hours a day and 7 days a week. I worry about my overhead and my employees every day. I am always trying to pay attention to my billing service and make sure that what we are billing out is coming in at least somewhat. Speaking of billing, did you know that on average( a brief episode in the 90s aside), with Obamacare and other marvelous legislature, physicians get reimbursed 30 to 40% of what they bill on a good day? Did you also know that it can take three months or more for it to come in? So, 30+ percent, 3 months after you do something. That is some screwed up math. No one in their right minds would work for those rates right? I can understand the national trend toward trade occupations. It seems like almost every day I see some sort of advertisement for a trade school and the immediate job opportunities it offers. Who wouldn’t find that attractive? Not having to wait until you are 26 to 30 years old before you make even the smallest of salaries? Benefits right away? Shift work that you may be able to take a break from when you are not at your place of work? Don’t mind if I do. At least these hard-working jobs offer returns more quickly in terms of costs of living and even lifestyle. I am not saying that I am ready to throw in the towel and attempt a trade. I am also not implying that one scenario is better than the other. There are trade-offs on both sides. I am just saying that the impression that doctors have it easy and have everything handed to them is grossly incorrect.

Now let’s talk about the statement that doctors just order tests and procedures to make money off of patients. Here is where I am only going to speak for myself. I am well aware that there are office and practices out them that may emphasize quantity over quality or that there are certain things that every patient has to have. That is not the case in my practice. I do not order a test or counsel a patient about a procedure unless I truly think she needs it. I have nothing to gain by ordering extra labs for example. I do not have a contract with the lab or receive any volume-based kickback. It’s just not a thing. With regard to procedures, there are some diagnoses that I cannot adequately assess without more information. For example, when I perform a pelvic exam and palpate some fullness in the ovarian fossa, I suspect that patient may have a cyst or a mass. I cannot tell which it is, if it has septations or other concerning features, or measure the exact size without a pelvic ultrasound. I have to pay my ultrasound tech to perform the procedure. If a patient has a polyp in the uterus, I cannot tell if it is benign or cancerous unless I take it out with a hysteroscopy. I am not deliberately trying to sit down and think of more ways to get more money out of patients. I am not in it for the money. I am in it for the people. Have a fantastic day!

Dr. Katz

I am not exactly traditional. I hope that’s ok…..or….don’t judge a book by it’s cover..

Well now, that is a potentially loaded sentence isn’t it? It has probably a million different meanings. Let me dive right in and explain how it applies to me. I am definitely not traditional in terms of my medical practice and how I deal with patients, or even how I look on the day to day basis. Let me explain first what I mean by traditional. If I take a patient poll right now regarding what my patients initially expect a doctor to look like and act like, the majority would answer something like this. They would expect a somewhat “stiff,” white coat wearing, dressed up, slightly haughty, talk at you not to you, somewhat patriarchal, person who would tell them what to do, use only traditional Western medicine, spend an inadequate amount of time with them, treat them like the next cattle in line, prescribe them something, and then walk out the door….after first making them wait an inordinate amount of time. Yes folks, it is true. A lot of patients have rather low expectations of their physicians and unfortunately, there seem to be too many physicians out there who meet those criteria. This is truly unfortunate and I do not really know how this got started. To take this a step further, it seems to throw patient’s off and actually scare them a little bit when a physician comes along who does not fit these check boxes. There seems to be a certain level of comfort that comes along with these low expectations. These low expectations actually help continue to foster the growing culture of doctor versus patient that seems to be developing in our country. The pervasive thought trend that all doctors are just out to make money and don’t actually care stems from these low expectations and is so harmful. It gets in the way of patient care, increases non-compliance and really damages the potential doctor patient relationship. I have actually had patients leave my practice because I did not fit these checkboxes! ( I was too thorough, talked too much, spent too much time on the visit..etc)

I am happy to report that I tend to not fit these check boxes. This is by careful and thoughtful design. I do not wear a white coat every day. I make eye contact. I talk with patients not at them. i am sometimes in the room for 45 min or more, because I feel like I will miss something important if i don’t spend enough time. I don’t dress to the nines every day. Mind you, I do not look like I just rolled out of bed either.( That is, unless I have been on call all night and there has literally been only 20 minutes to get myself together and run to the office. I need to let myself have some leeway there.) My scrub uniform is pink with pretty black lacy letters. My hair is black cherry and blonde. Dag gum it I even have tattoos!( cue gasp) Sometimes this really sets patients back a beat when they first meet me and it affects how they react to me.

Let me give you an extreme example. Ever the fan of a social experiment, when I was a wee babe in my 30s when I first started, I used to put my hair in two pony tails sometimes when I operated on patients. I did this for several reasons. 1) It sometimes gets really hot in the OR! 2) My hair was too short to fit it into one ponytail at the time and 3) I wanted to see if patients and families would react to my input differently based upon how I looked. Wow it really did! I would go to the family waiting room, with my ID badge in plain site, explain the details of an intricate operation and how I just saved a loved one’s life. The family would listen with complete attention…and then proceed to ask me at the end when the doctor was coming to talk to them! I would politely inform them that I was the physician and refer to my ID badge and they would respond with polite surprise. That stuff never happened when I nixed the pony tails and just wore my hair down. Besides this just being an interesting little past story, my point is that society really seems to judge their physicians, and even their offices, by appearance. We like that snazzy dresser with the beautiful state of the art office, even if their service is terrible and the results aren’t what we would like. This is not the way to go and the best way to measure physician quality. Trust me, I have been in some absolutely beautiful offices with very glamorous physicians …..who I would not go back to if you paid me because the care that I got was not worth it! I love beautiful offices and people as much as anybody, but those are not what I base my doctor selection on. The real measure of quality of a physician should not be how the office looks or how well he or she dresses. It shouldn’t be how quickly you get out of there or how often you can “get what you want” from them or what pills he or she gave you. It should be measured by the quality of the service, how much time the physician spent with you, whether the staff was courteous and helpful, whether you felt comfortable at the office, and whether your concerns were addressed appropriately. These are the real measures of a physician and his or her office. Now I am not saying that you should go to a doctors office that’s seedy, dirty, disorganized and the doctor looks like he or she just rolled out of bed. There are certain basic requirements to instill basic confidence. I am just saying that appearance should not be the only thing. Bottom line, if you are scared off by tattoos, trendy hair or someone that talks with you and addresses all your concerns to the fullest, then I am not the physician for you. Otherwise, let’s start a great patient physician care partnership together and I look forward to helping you. Have a wonderful day!

Dr. Katz

It’s Just a Job

I saw someone post on Facebook the other day…People at work are not your friends. It’s just a job. Do your job. Go home. I also hear people say ” It’s just a job.” far too often. While I get that we are always told not to bring our work home with us and to make sure that we have healthy work and life balance, I am not sure that that is what that statement really means. For the majority of folks, if you were to ask them about their current employment, they might respond with a somewhat dismissive, “It’s just a job.” I think that this response it somewhat a metaphor for the troubles with work ethic and even life ethic that seem to plague us. As an employer( and an employee), when someone says it’s just a job, here is what I hear. ” It’s just a job. I don’t actually care that much. At least I am only somewhat responsible during my shift, which I hate showing up to and then I am free as a bird after that. I can always dump what I didn’t finish on the next person. It is a means to make some money, but that is it..and even knowing that, I don’t really appreciate the fact that it is helping me pay my bills and be able to live. I don’t really care that I am lucky to have a job and lots of other people don’t. I have no sense of true commitment or loyalty to my boss and I have no ties to my work colleagues. And finally, I literally never even think about my job or what I am responsible for when I am away from it and if I forget something, oh well.”

Ok I get it, that is adding a lot of weight to one sentence, but I really think that it is applicable. I think some of us have lost our sense of value and ethics when it comes to work. On top of that, inflation aside, we expect to get more pay for doing less because we are somehow owed. I get that not all jobs have the same level of objectively measured importance, but they are still important for different reasons. Each and every job has an associated goal that requires completion for the rest of the steps to continue. Even a ditch digger has to complete the required depth and width to be able to accommodate whatever object is to be buried and if they don’t the rest of the project cannot continue. True, it is possible that no one’s life in particular will be significantly affected by it, but it is still important nonetheless. I cannot think of any job that is not interconnected to another one in some way or that wouldn’t be improved by some real investment on the part of it’s employees. In my office, this is particularly true. I am a physician and I also practice aesthetics. My job is essentially runs 24 hours a day, 7 days a week. There is never a time when I am not responsible for the lives of my patients. I get that. I embrace it AND.. I knew what I was signing up for so I tend not to complain. To me, it is a sacred honor and privilege to be able to care for people and I reremind myself of this every day, even on the worst days. I am that weirdo in the operating room that takes an additional pause after the surgical pause to reflect on how lucky we are to be able to be here for this patient, for this procedure. I worked hard to get here and I am not leaving any time soon. I know that I am never really “off the hook” when it comes to patients. I don’t ever really leave the office even when I leave it physically. But, it’s ok. I love what I do. I am grateful for what I do. I will always be grateful for what I do. I take care of my employees and patients like family. I would do anything for them. I keep working whether I get paid or not so that I can take care of my employees. Do I expect my employees to be on call 24 hours a day, 7 days a week like I do? No. Do I expect them to be there as late as I am all the time? No. Do I expect them to have the same crazy level of work ethic that I do? No. Their level of responsibility is not the same, but they are responsible nonetheless. I do expect them to complete their jobs to the fullest. I do expect them to go through some checks and balances each day BEFORE they leave to make sure that all tasks are completed, all referrals are in, all labs are called, all scripts were sent, etc. I expect them to not directly refuse tasks or passive-aggressively avoid them and think I won’t notice. I expect them to have a team mentality and realize that we are all incredibly important in providing the best care for our patients. Even though the only cog in the wheel that really can’t be replaced is myself, they need to understand that I will value each and every one of them and treat them with respect. Having said that, I also hope that they realize that respect is a mutually earned commodity and it has to be given and returned in kind.

I hear stories from employees from an older generation about incredible abuse they suffered in the workplace that went on for years and years and how they kept coming back for more because ” that’s what you did in those days.” I hear about how they were insulted, made fun of, worked with no breaks, had to cover for their boss’ alcoholism and had to make excuses for them if they failed to show up for procedures, etc. Compare that to nowadays when employees quit over proverbial hangnails and there is no comparison. I have to admit, when I first hear those stories, I find myself thinking oh I wish I could even get a fraction of that loyalty. Then, I catch myself because I realize that those situations were not about loyalty. They were just about frank abuse and I don’t want any part of that. I am not converting myself into an asshole to get people to do what I want. It’s just not me. I feel like we should be able to meet somewhere in the middle. I have no idea why employees of yore put up with such terrible things to keep their jobs. I suspect that it is at least partially a reflection of our former extremely patriarchal society. I am not sorry that some of that has gone the way of the dodo, but I feel like we have gone too far in dropping our level of work ethic. Now employees feel like they can quit with no notice, no show no call for work, talk back and refuse to complete tasks. How did we get so far off track? I don’t really have the answer but I have some theories. I think that our culture has slowly transformed into one of ever-decreasing actualization of responsibility in everything that we do. If something doesn’t work out? Oh well. If a child is acting must be his or her parent’s fault. If someone does something wrong, incomplete, or incorrect, we cannot even attempt to guide them without being misinterpreted as belittling or chastising and get written up. We are dealing with an overall decreased actualization of responsibility without the tools to deal with it because the potential repercussions of trying to deal with it are sometimes worse than whatever went wrong in the first place! How exhausting is that crap?

For myself, I keep plugging away hoping that my work ethic somehow becomes infectious and spreads to those around me. I offer uncapped incentives for hard work, on top of salaries. I am truly a believer in the phrase,” you get out what you put in” and I want to make that true for my employees. The ones that work harder will get rewarded with raises and incentives, but I do not want to, nor can I afford to, give it away. I desperately want them to be invested in their work and this is the most clever way I can think of to try to make that happen, by having something in it for them besides just work pride. I cannot really chastise people for wanting more money. I mean, who doesn’t want more money? That is a pretty normal human want. I am just hopeful that they see that they have all the tools to be successful financially and at the work place, as long as they put in the effort it takes to be so. It is a potential win win for everybody…the patients, themselves and for the longevity of our practice. Well, those are my thoughts. Have a fantastic day everyone!

Dr. Katz

All cancers matter

I saw this bumper sticker yesterday when I was driving. It said all cancers matter, NOT just breast cancer. Then it was surrounded by various colored ribbons for different cancers. I shouldn’t really call it a bumper sticker. It looked like someone did some cricut decal letters then put a bunch of ribbons around it. It took up half the back windshield.

I have to say this set of decals really got to me…and not on a positive level. My first thought was fairly random like wow! How can that person see out of their window any more? The rest that followed were more of a serious nature. It almost stunned me how angry that person must be and how much it must be clouding their thinking. I wondered how they got to thinking that one cancer “gets too much attention” if having cancer is a popularity contest and you have to have the right one in order to have anybody notice. I wondered how they got to be so resentful? I would pretty much assume that all any diagnosis of cancer can be life-changing, if not possibly life-ending, regardless of type. I think that all my energy would be devoted to just general resentment of having the disease, not if my disease got less attention than another one. I had my own cancer scare last year and I feel confident in stating that I did not spend any time resenting other diseases that were “stealing my spotlight.” I do see how one could think that breast cancer does get a lot of devoted research time and “publicity.”..but I also think that the research time spent on a particular disease has to be proportionately driven by how common the disease is and how many people it affects. I don’t truly think that it is a deliberate slight toward other diseases or an indication of their importance. Research dollars are still a finite commodity and there are a multitude of checks, balances and endless hurdles to leap before it can even be decided where to spend them. I suppose the importance of a particular disease or cancer can only truly be assessed by the patient and his or her family, since they are the ones truly affected by it. To the patient, it doesn’t matter of his or her disease is rare or if it affects 25% of the population. Welp. In the immortal words of Forrest Gump…that’s all I have to say about that. Have a fantastic day!

Dr. Katz

Soo..when should you take your kid to the gynecologist?

Well i am glad you asked! Being a gynecologist myself, I am ALL OVER this one with wise tips and safe knowledge. First let me say that yes, I have seen all the newsflash and articles about teens suffering through unnecessary exams too early. Yes yes. I have read them all. I am also well-versed in all the national recommendations. Having said that, let me break this down according to my perspective and explain how I go about the practice of adolescent gynecology.

I want to first start off by saying that, to my knowledge, no teen has suffered at my office that I know of….or at least they have not spoken up. Usually they leave the office relieved that it wasn’t as awful as their friends, google, or the random promiscuous acquaintance said it would be.

Ok let’s clarify some current national recommendations on pap smears. The USPSTF( United States Preventative Services Task Force) recommends screening for cervical cancer in women ages 21 to 65 years with a pap smear every 3 years or, for women age 30 to 65 who want to lengthen the screening interval, screening with a pap smear and hpv testing every 5 years. Women over the age of 65 with adequate prior screening do not require further screening. Women who have had a hysterectomy with the removal of the cervix and who do not have a history of high grade dysplasia also do not require further screening. Now that we have all that settled there are a few caveats and things to clarify. First, these recommendations are based on statistics, costs( how expensive it is to identify and take care of someone with cervical cancer versus how much it costs to screen everybody) and epidemiology( how long it would take abnormal cervical cells to progress into something serious. Second, these recommendations often come from a panel of folks who may or may not have seen actual patients in a clinical setting in a very long time. Third, these recommendation ONLY refer to the pap smear guidelines. This can be very confusing for women because when they hear no pap smear required, they tend to think that means no exam is required. I cannot speak for other offices, but in my office, the pap smear is a mere 30 second portion of the entire head to toe exam that I perform on my patients and is by no means the end all be all. This is, in my opinion, potentially very dangerous because there are many gynecologic conditions that do not present with symptoms until late stage and increased severity. If the average woman gets no check up and just waits for symptoms, she could already be facing a life-threatening condition that could have otherwise been picked up on and treated. Ovarian cancer symptoms can be as vague as some bloating and decreased appetite. Vulvar cancer can present with just a minor itch. Without significant contortionist abilities, a head lamp, and some Superman x ray vision, I find it difficult to believe that the majority of women could accurately self- diagnose at an early stage. I recommend at least getting an exam every year…all pap smear recommendations aside. The other thing that I find difficult to swallow about these recommendations is that they seem to be attempting to weigh what a human life is worth. It feels like we are saying,” It’s just too expensive to watch out for all of you long term and actually use our technology to catch everything early, so we are just going to hedge our bets and go for the cheapest option because it will likely end up in our favor. For that handful or more of patients that get missed, oh well. I would challenge any actively practicing physician to look a patient whose preventable diagnoses was delayed and hide behind these recommendations with no regret.

Now, back to the teenagers. Let me preface again before we go on that what I am about to say is based on fact and my personal opinion combined. I will try to be very clear on which part is which. Here is what I tell parents when they ask when they should bring their teenage daughters to me. I first recommend that a patient start visiting me when she first starts having a period. This is a good time to have an honest, CLOTHING ON, discussion with the adolescent about her body, what to expect, evaluate whether she is having any menstrual difficulties, etc. If applicable, we can also have an open discussion about sexual pressures and peer pressure. I also use this as an opportunity to offer myself as an unlimited resource for any future questions she might have. This visit does not necessarily involve getting an exam. These kinds of visits can be carried out on an annual basis, accounting for good decision-making, until the patient reaches 21 and screening can begin. However, we all know that age of first intercourse in the United States is getting lower and lower. I have 12 and 13 year olds in my practice that are already experimenting with sex. A lot of the time, the parents either do not know or are not prepared or comfortable to deal with this situation and therefore the patient goes unchecked, high risk behaviors evolve out of lack of resources and information, and lots of potential problems arise. I truly feel that if these patients were to have the opportunity to establish with me, I could help tackle some of these issues and at least attempt to help keep the patient safe. If I have an adolescent patient that is engaging in high risk behaviors( multiple partners, unprotected sex, etc), I may want to do an exam for several reasons. First, even tho I realize that some sexually transmitted infections can be screened with urine and blood, there are some that cannot. For example, I cannot determine if a patient has genital warts that need to be treated without an actual examination. Second, it is my personal opinion that there is a certain amount of responsibility that should accompany the decision to be sexually active and part of that should include the patient being actively involved with being healthy like getting an exam rather than peeing in a cup and waiting for results. I think that when we foster a disconnect between our teenagers and their decisions, it only compounds the potential for disaster. Third, this subgroup of teenagers is at higher risk of HPV and eventually cervical cancer. I realize that, according to statistics and epidemiology, it is likely to take years and years for this HPV or cervical dysplasia to develop into something serious like cancer and that it has a chance of resolving on its own. I also realize that part of the logic in these recommendations is that the teenage population would be more at risk for having unnecessary procedures for conditions that may resolve spontaneously in time. I assure you that I am very cognizant of not doing just that in my practice. Even understanding all that, do we really want to just throw the dice and wait and not even involve the adolescent in her own gynecologic well- being until she is 21? I just have a hard time with it. Welp, those are my thoughts on the subject. Have a fantastic day!

Dr. Katz

What is a healthy relationship?

Ok I am going to say it. My husband truly is my best friend, but what does that actually mean? Are there different criteria for besties you are married to versus ones that you are not married to or in a relationship with? I don’t actually know the answer to this one, but I can define what I mean when I say it. I mean that my husband is the first person I think of to talk about my day with, to tell a secret to, to giggle with, to hold hands with, to spend the day with, or to just sit and do nothing with. He really is at the top of the list. I still get a stupid smile on my face( most of the time) when I think of him or refer to him in conversation. We still have a lot of fun. That’s my definition of a best friend. This does not mean that we never fight or argue, but we have never resorted to hitting or any other violence. This does not mean that sometimes I don’t get so pissed off at him that I don’t want to speak to him for awhile. Both spectrums are fully represented. No one can make me happier and no one can make me angrier. Gladly, these two situations don’t usually present at the same time, if you don’t count menopausal hormone swings. I still have other friends and I still lead my own independent life with my own goals and pursuits. I travel alone for business or with friends sometimes. I “do my own thing.” He is not up my proverbial butt all the time. I still consider that pretty normal and healthy.

Sometimes when people say those words, they mean something entirely different and, in my opinion, not so healthy. I know people who talk about their partners being their best friends and what I see, as an outside observer, is a relationship that is fraught with obsession, possession, and pathologic co-dependence. They are attached at the proverbial hip with their partners. They identify themselves only as a matched set. They are uncertain of who they are when their partner is not around. They have no outside friends or unshared activities. They have a habit of checking/seeking permission from their partner to do anything. They don’t speak their minds for fear of starting an argument. To me, this is unhealthy and potentially leads down a slippery slope to a controlling or even abusive relationship. I get that traditionally we think of an abusive relationship in terms of physical abuse, but emotional abuse leaves just many scars and they last longer.

So, what is a healthy relationship? I find that this is a question that seems to be getting more and more difficult to answer for both adults and adolescents. Did you know that roughly 1.5 million high school boys and girls in the U.S admit to being intentionally harmed or abused in a relationship at one point and that 1 in 3 young people will be in an abusive or unhealthy relationship at some point in their lives. That means that 33% of adolescents in America are victim to sexual, physical, verbal, or emotional dating abuse. This behavior is starting as young as six th grade! Young women who are in an abusive relationship are 6 times more likely to become pregnant or contract a sexually transmitted infection and are 50% more likely to attempt suicide. Add on top of this that most of this abuse goes unreported because of fear of exposure or just lack of knowledge about possible recourse. The stats for adults are not any better in terms of unhealthy relationships. Did you know that a woman is assaulted or beaten every nine seconds in the United States. 1 in 3 women, and 1 in 4 men, have been in abusive relationships. 1 in 5 women and 1 in 7 men have faced severe physical violence as well. 20 people are abused by an intimate partner every minute, which adds up to 10 million people each year. Just like with the teens, up to 75% of this is not reported.

Ever time I look at those statistics, I am sobered once more about the reality of them. Still, I feel that awareness is an essential ingredient in targeting this devastating issue. This is truly a situation in which putting your head in the sand can make a life or death difference. I deal with domestic violence in my office frequently. I have a confidential questionnaire that each patients fills out with her visit that starts off with some generalized questions and slowly leads up to questions about domestic violence. This way, she can fill it out confidentially and then we can open up a dialogue once she is safely back in an exam room. Sometimes, I am the first person who has ever even asked the question in her whole life. These are often women who have friends, relatives etc who have seen bruises or noticed behaviors but don’t consider it their place or are afraid to mention it for fear of repercussions and or potential danger to themselves.

I think that sometimes abuse victims face a culture of blame. Myths about domestic violence are common, particularly among those who are likely to abuse their partners. Some people say that if they get hit, they will hit back and then the next bit of twisted logic is that women who slap their partners should expect whatever violence their partner can dish out because they deserve it. I hear women say that they got ” what was coming to them” as a result of a particular behavior. This is false! There is no behavior that justifies physical violence or emotional abuse. All of these myths contribute to an overall culture of violence and victim-shaming.

People talk about the victim as being a part of the cycle of abuse and have no idea why the person doesn’t leave the relationship. This is an easy statement to make on the outside, but these same people are not intimately involved in that relationship. They don’t realize what is potentially at stake with leaving. Sometimes there are children involved and the victim feels that they will be more at risk with leaving. Sometimes there is a very real danger that the victim themselves may be killed if they try to leave. Sometimes the victim cannot leave because their partner offers financial security. Victims talk about the very strong psychological pull of the ” honeymoon period.” The honeymoon period is that period of calm when things appear good again and the abuser has apologize and made temporary changes and restored the often desperate and fleeting hope that the victim has that the relationship can be saved. I have patients tell me that this honeymoon period is all that have to live for at certain points because they are so broken by the abuse and the relationship that they can no longer see or evaluate their lives clearly.

So, how do you spot an abusive relationship? What are the signs?

1. Humiliating or embarrassing you

2. Constant put-downs

3. Hypercriticism

4. Refusing to communicate

5. ignoring or excluding you

6. Affairs with other people

7. Provocative behavior with the opposite sex

8. Unreasonable jealousy

9. Extreme moodiness

10.Mean jokes or making fun of you

11.saying ” I love you, but…

12. Guilt trips

13. Domination and control

14. Making everything your fault

15. Withdrawal of affection

16. Isolating you from friends and family

17. Using money to control

18. Constant calling or texting when you are not with them

19. Threatening to commit suicide if you leave

Ok now that you know the signs. What do you do about it? What do you do when you notice it in someone else’s relationship? If you are the victim, the obvious, but not easy, answer is to break off the relationship and leave. Call the National Domestic Violence Hotline at 1-800-799-SAFE. All phone calls are confidential. This is a 24 hour hotline to talk confidentially with anyone in the United States who is experiencing domestic violence, seeking information, or questioning if his or her relationship is unhealthy. This same hotline also provides lifesaving tools and immediate support to empower victims and survivors and also provides support to friends and family. They have an online chat as well if you do not feel comfortable or are unable to call. If you are the observer, don’t wait for the victim to approach you. Ask them in private and let them know your concerns. Tactfully point out the signs that you have noticed. Offer to be there for them to talk and promise confidentiality. Direct the victim toward resources such as the national hotline. You could save a life. Have a fantastic day!

Dr. Katz