Positive Reinforcement 


My work life has not always been wonderful. I have struggled to learn how to deal with coworkers, patients, and teachers fairly frequently. Maybe I should have read that damn book my Grandaddy gave me when I was 8. Carnegie reportedly had all the answers for how to get along better. I’ve read it since and it basically boils down to being nice and considerate of others. 

I have a rather polarizing personality. You either like me a lot or you can’t stand to be around me. I don’t inspire much apathy. It has taken me years to mellow out and stop carrying a chip around on my shoulder. I also had a horrible inferiority complex. I knew I was different than other people and I assumed that was a bad thing. I never felt competent, nevermind successful. I just knew I was not good enough. 

So, I worked hard and tried to prove myself. Well, actually I turned into an insufferable asshole. People thought I was judging them, but the person I actually despised was myself. So, I overcompensated. I was a jerk. A completely unhappy jerk. 

It made work difficult. I own it. I made lots of mistakes. I just wanted to be better. I wanted to be worthy. 

I was shocked when my dream job didn’t solve the problem. All the people I had pissed off throughout my career were not impressed. All they saw was an asshole who apparently thought she was special. Little did they know I was wracked with self-doubt and insecurity. 

I loved my job though. I wanted to be good at it. I wanted to make the people who had invested time and energy into teaching me proud. I just wanted to deserve their respect. Unfortunately, I had left a trail of people behind me who remembered the wreckage of my feeble attempts to prove my worth. So, they were watching and expecting me to fail. They viewed every single thing I did through a lens clouded with disdain. There was no way for me to earn their respect. Who the hell did I think I was? So,  my insecurity grew. It became a cycle. I cried a lot. I think the most confusing part for me was the incongruity between my sincere love for my job and my misery. 

I suffered from mood swings and my attitude was completely unpredictable. I was either sullen and snarky or overly sweet and disingenuous. I reeked of insincerity. I was moderately paranoid that everyone was out to get me. To be honest, some were. Not all though. I was losing my mind. I could not understand why getting exactly what I wanted had not made me happy. 

I don’t mean to make it sound like it was all bad. It wasn’t. I had some people take me under their wing and coach me until I was actually pretty good at my job. There were many times I was included and made to feel like I was a valuable member of the team. I had people give me their time and expertise freely. They didn’t have to do so much for me. The physicians, pharmacists, and other healthcare providers who invested their energy in developing my skills are the reason I can do this job now. I am so grateful. I hope they know how much I appreciate them.

Fast forward past a very dark time when it became apparent I was not going to be able to overcome all the challenges associated with the job I loved so desperately. I started working as a Locum. I love a lot about this lifestyle. I get to decide when and where I work. I get to move on when I am bored. I have met people all over the country. 

I think I have gotten better at my job. I am able to walk into new situations with confidence. I am not competing with the imaginary person I think I should be anymore. This is important. This confidence has allowed me to stop trying to prove myself constantly. It’s a relief. I allow myself to talk to my patients like they are people instead of patients. I am so much happier. I am a better provider because of it. 

I wouldn’t trade my past for anything. That experience was wonderful and painful at the same time. Now there are times I miss my old job. I miss the familiarity of being with people who have known me for all these years. Sometimes I feel untethered and unattached. So, I keep in touch. My former coworkers have not left my life, they just have a different role. They are my friends. A couple are my best friends. They have seen me at my best and my worst. They are on my side. 

It feels weird to receive compliments, especially written ones. This patient and her family were a joy to work with. It was an honor. This little note gave me some positive reinforcement to keep doing my best. Not because I have a past to atone for, but because my patients, coworkers, and I deserve my best. 

Terminal Waiting


Your wife sits on the plastic sofa, struggling to hide the misery marching across her face. The nurse sits beside her prepared to attempt to soften the blow of our discussion. You are tucked into the recliner with your heavy, waterlogged legs elevated to help reduce the swelling. Your face is painted with the pallor reserved for the poor souls who have survived septic shock. The air is tainted with a musty, decaying, chemical pollution reserved for Intensive Care Units. 

The appropriate demeanor escapes me  as I struggle to find the correct tone for the questions I have to answer on this obscenely neon form. The bright orange paper would be better utilized on a hunting lease. My fingers are cramping under the strain of my attempts to hold my trembling at bay. The gravity of this conversation intimidates me. I am horribly under- qualified for this. 
I scoot the bedside table out from between us and take a seat on the freshly made hospital bed. I attempt something like a smile. Would it be terribly inappropriate for me to crack a joke? Do I minimize the seriousness of this talk? 

Slow, deep breath. 

I intentionally avoid eye contact with your sweet spouse. This is your decision. One of the few things you still have complete control over. I owe it to you to not mess this up. 

“So, I have a form that I have to discuss with you before I can send you home. I know you have already had this discussion, but I have to clarify the specifics and record it so we have a record of your wishes.” 

I glance down at the first item, Cardiopulmonary Resuscitation. CPR. A horrifying act which can sometimes saves a life. I have to ask you whether you want someone to attempt to intervene if your heart stops beating. 

Usually, I make a point to say that I ask everyone this question and reassure my patient I am not anticipating this issue. 

Today, I am sending you home to stop treating your terminal disease. I am tasked with clarifying your directives to healthcare providers. 

“Joe, the first thing on this form is if you want someone to attempt to restart your heart if it stops.” 

You shake your head no. 


Strange how such a permanent decision is indicated with a check mark. It feels like there should be at least a paragraph written there. Perhaps a reassurance to everyone they are doing the right thing. How can doing nothing be the right thing? 

The next item addressed several different options if you develop respiratory failure. I have to ask about each one. 

“If you stop breathing or if your breathing is ineffective do you want to have a tube placed so we can put you on a ventilator?” 

Vigorous head shake. 

“Even if it could be a temporary or reversible problem?” 

Slight hesitation. You mutter something that resembles a no. 

“Would you want noninvasive mechanical ventilation, which is a mask that provides pressure and can sometimes help?” 

I get a blank stare. 

“Ummm. Joe if you begin to have trouble breathing do you want to be brought to the hospital for us to attempt to keep you alive with machines? Even if they would not require intubation?” 

I wait while you appear to consider these options. Finally you glance at your wife and whisper “no.” 

I go through the rest of the details spelled out on the form. Coming to the hospital if your condition becomes worse. Artificial nutrition if you is unable to eat. Intravenous hydration if you cannot not drink. 

I have stutter and stammer my way through each question. I fight the urge to try to convince you to keep fighting. I want to encourage you to “beat the cancer!” This is just a battle, I know you can win the war. 

I look over at your wife and realize she is crying. I desperately need to fix this. I need to give her hope. I look down at the form you have painstakingly signed and initialed and read the most annoying words possible. 

Black Ink Only. 

I glare down at my blue pen. The blue and orange remind me of the colors the football team wore when I was in high school. 

I also realize my cell phone number is written in the forbidden blue ink instead of the office number as my contact number. 

I don’t want to admit my ineptitude. I want you and your wife to trust I have done everything the way I should. I don’t want to give you a reason to doubt your decision. I pull my pager out of my pocket as if is vibrating an alert. I rush back to the nurse’s station and ask for the form. 

“We already gave it to you.” 

Now I have to admit my inability to follow directions to someone else. I start choking and coughing as acid comes from my churning stomach burning the back of my throat. 

It turns out they have run out of the orange paper. She can’t print me a new copy. EMS is here waiting to transport you home and I have not even written your prescriptions. 

Finally someone finds me a new form on a different floor. I stand at the counter and carefully fill out everything but your signature. 

I walk back into the room and lie. I tell you I was unaware there had to be two copies. 

Everyone knows this is not true. You graciously let my obvious gaffe slide. I ask you if you need anything else. 

“Yes. I do. I need a hug.” 

I can barely compose myself. A few tears manage to escape. The lump in my throat prevents me from speaking. So, I lean down and give you a hug. 

“Thank you for taking care of me. Now, is it okay if I take my pills with a shot of Knob Creek?” 

All four of us bust out laughing. 

“Well, you are dying. You can do whatever you want.” 

I brace myself for the stony silence I generally earn when I say something exceptionally blunt. Instead, all three of you laugh even harder. 

I have to excuse myself to write the prescriptions you need to fill before you get home. I know I will never see you again, so I take the chance to hug you and your wife one more time. 

I’m not gonna lie, more than a few tears were shed on the drive home that night. 

Third Time’s a Charm???


Sunset arriving in Tulsa. It is beautiful. Until I walk through the sweltering, damp heat to the rental car.  I am sure I am destined to drown in the humidity. Get to the window and wouldn’t you know it? There is a line. I stand there and sweat. Ask politely for a car with Bluetooth. Get a rocking minivan. 

This morning I wake up exceptionally early. I do not have to be at work until two, and I am up before seven. 

Finally, it’s time to head out to work. I’m nervous and probably should not have eaten Jack in the Box for lunch. I just love fried lettuce. I can’t help myself. 

Get to work, find the right building, and walk in for my appointment. Training on the EMR. This seems to be rather simple. I’m relieved. This is one of the hardest parts of working this way. Lots of new programs to learn. New docs and nurses. So many names and new hallways. I always feel a little overloaded and lost for a couple of weeks. 

I am never sure how much to talk. I have a tendency to either babble or sit in sullen (not intentionally) silence. This new doc seems pretty cool. 

I follow a gregarious NP. He really cracks me up. It is such a relief to be around friendly people. At my last job, I was shunned a little at first. This is so much better. 

I watch these providers carefully, sizing up their professional interactions and monitor their sense of humor. I need people who don’t take themselves too seriously. I like work to be fun. This job is hard enough without the added stress of working with pompous assholes. 

Listening to patient/ provider interactions and I feel like I could work here. I am finally back in a world where I know what to expect. Critical care just makes sense to me. The providers seem to balance the work fairly among each other. I feel like they work well as a mutually respectful team. 

This is what I have been missing. I think I am going to enjoy this assignment. I appreciate how everyone is welcoming me into the mix.

Honestly, I wish I had come here six months ago. I know it has only been one day, and it was a “easy” night, but I like the atmosphere. Perhaps the third time is a charm. We shall see. 



  I am learning so much, mostly because I know so little. Some people are hesitant to admit their ignorance about certain topics, I am not. It’s embarrassing, sometimes. 
I have never lived somewhere with a radiator. In Texas, central heat and air reigns supreme. The radiator makes strange noises in the night, if I did not know better, I would be nervous. 

Working on a surgical service is completely different than working on a medicine service. I always knew this was true, but I never really knew the surgery side of things. 

Not all residents are douchebags. You would think I would have already learned this, however most of my experience with residents has been minimal exposure. The residents I am working with are nice and quite willing to make me feel welcome. I don’t feel like they are waiting for opportunities to make me feel inadequate. This is truly a welcoming learning environment. 

Physicians are not all natural teachers, however once you express interest in their passions they will stop and spend some time explaining their expertise to you. 

I am having fun. I am exhausted by all the new ideas. 

I am still a newbie and I have a lot to learn. So excited! 

First Day Jitters


 First of all, I LOVE my apartment. It is the first floor of an old house. I am learning about steam radiators and getting used to all the cool noises old homes make in the night. Seriously, it is beyond charming. The owner was amazing. He gave me advice on local points of interest and made me feel very welcome. I could not have asked for a better reception. 
I went to bed incredibly early last night. I was exhausted from all the traveling and more than a little mind blown by all the sights. This area is beautiful! 

Getting ready for my first day of orientation. Yep, I’m nervous. What if they don’t like me? What if I’m not quite as clever as I think I am? (We all know I crack myself up on a regular basis.) Excited and nervous. I think a third cup of coffee is a good idea. 

People keep telling me they are proud of me for seeking these new adventures. I find that hilarious. I was feeling like I was behind. Somehow I should have started all this years ago. Nope. I’m right on schedule. 

Wish me luck. Cross your fingers my hair does what it is supposed to do. Let me be calm and professional. I need to keep the first day jitters down to a dull roar. Adventures are fun. It is so much more than I expected. 

Thinking Problems


imagesI may as well admit it, I have a thinking problem.

I continue to over analyze and obsess over every thing that pops into my head. I think it is because I am back to waiting to see when I am going to my new job. Waiting for licensure and credentialing to be completed is agonizing.

I hate waiting.

While I wait, I ruminate.







When is all of this angst ever productive? In my experience, never. So, why do I continue to make myself crazy? I think it may be habit. I refuse to be one of those people who rush into decisions without having thought it all the way through. People who rush into things drive me crazy. Life decisions should be carefully considered.

My anxiety about making decisions is often misguided and borders on ridiculous. By the time I am done going over my options I no longer care which option I choose. I almost always have immediate buyer’s remorse. I should have gotten the other one. I also do the thing where I can’t decide between two options and I either get both, or neither. I have to tell sales people to stay away from me when I am making large purchases. If they are over there prattling on about the features and differences between two options, I get overwhelmed and change my mind. It is really a little embarrassing.

Big life decisions about where I want to work or live are often better left to chance. I do better if I am well-informed, but then when I am going about making the choice I try to see what works out best. The problem with this attitude is I am running the risk of making a choice because it is logistically simpler. Sometimes it is because there is less paperwork involved. I hate paperwork. I don’t like signing stuff and I REALLY don’t like signing stuff again.

I am trying to learn how to back off and relax while still evaluating decisions objectively. I am still trying to figure what characteristics are paramount and which are simply preferences. Location and money are important factors but not as desirable as an excellent learning opportunity. I have not figured out a scale to measure and evaluate decision yet. I think assigning traits a weight would help more than a simple pro and con checklist. What about things that are both pro and con? How do you measure which side wins?

I even manage to get weighed down with the decision to make a decision. It is somewhat ludicrous. Here I am trying to ascertain the proper method for ascertaining what I want out of life. I am actually starting to believe the most important skill of highly successful people must be the ability to decide and follow through with their decision. Where do you learn that skill?

So, where is the delineation between purposeful consideration and needless obsession? How does one go about making a decision and standing behind it with confidence?

Most importantly: How on earth do you make your brain turn off for a little while so you can get some sleep?

I am Lucky and Working Holidays


Hospitals do not close for the holidays. This means healthcare providers have to spend time away from their families and go to work. I have never minded working holidays. To be completely honest, I consider it a privilege.

When patients are in the hospital on a holiday, it is the last place in the world they want to be. We do not typically schedule elective procedures during those times. The people who have to be admitted usually have no other option.

I do not see any point in refusing to work on a holiday when we celebrate locally. I can go spend a couple of hours with my family or even celebrate another day, it is not a big deal to me. My family will fix me a plate, or even send a huge spread of food for me to share with my coworkers.

Christmas Eve of 2013 I was at work in the MICU. The unit was full and we were slammed when I get a phone call from my mother saying my brother, sister-in-law, and two nephews were in a bad car accident outside a small town about two and half hours away. They had been traveling to visit her family. We were not able to get much information about their condition over the phone and my sister-in-law had already been transferred to a larger hospital.

I dropped everything and went to go take care of my family. That drive was so long and I have never been more desperate to get more miles between me and Lubbock, Texas. I had to get to my brother and my nephews. When I finally arrived to the hospital, my nephews were in a hospital room filled with toys. They had been doted on and loved by so many people. Someone had gone and bought them some clothes to change into because theirs were dirty. DPS had brought them teddy bears. I believe it was a nurse’s aide who went and bought them cars and trucks from somewhere. I have never been more grateful. My boys were okay.

Christmas that year was terrible. My brother could barely move and could not see due to his injuries. His wife was in the hospital preparing to have the first of many surgeries. The boys were very stressed out, although physically they were okay. I would have much rather have been able to work that holiday.

My family is okay if I am working. There are no big personal tragedies or crises. I can focus on my work because my family is safe and healthy. If I have to leave work because someone is hurt or sick I am a mess. Work is so much easier. Once the day is over I get to go home and escape whatever nightmares transpired at the hospital.

I can devote a few hours to another person who is having a bad holiday due to their medical condition. I can spend time with a family who is saying goodbye to their loved one on that day. It is the least I can do. I did not lose my family when they had an accident on Christmas Eve. We were lucky.

My role as a healthcare provider is important to me. It is humbling and I am proud of the career I chose. I have worked hard to be able to help people. I sacrifice a lot of time with my family and friends. I work long days and some days it is so hard.

However, I will keep working holidays. I will do my best to provide care to my patients and their families when they really just want to be at home celebrating. It is my way of showing my gratitude for my good fortune.

If you find yourself or your family in the hospital on a holiday, I imagine there are more people who do not resent caring for you. If their family is like mine they will be gracious and understanding of the service we provide in our professional lives. We adapt and adjust our plans so we can be of use. Don’t worry, we are not being left out of the festivities. If we are lucky, we are good friends with our coworkers and they have become extended family anyway. It is the least we can do.

The Conversation


I know this is a difficult conversation for you. It is hard for me too. While I was walking down the hall to this room, I was secretly hoping for a miracle, a sign that we had made a mistake and everything was going to be okay.

I have been taking care of your loved one for a while now. We have used every tool we have available to heal him. Unfortunately, it does not appear that he will ever be the person he was before. No, he is not going to wake up and be okay. I understand you believe this is all in God’s hands, but it is time to make some decisions about where to go from here.

His body cannot survive without the machines that are supporting him. I know he has made some progress. His blood pressure and heart rate are normal. However, he is now dependent on dialysis because his kidneys have stopped functioning. He is not going to be able to breathe without the ventilator.

Where do we go from here?

Have you ever had the discussion with him about his wishes?

There is are no further medical interventions left to try. This is the new reality. There are few resources available for people in this condition. What quality of life can one expect in this condition?

I know you had hoped for a different result. Yes, he is a fighter.

This conversation never gets easier. It always hurts and I always wish I could be anywhere else. I often wonder how I would feel if it were my family member, and I try to remember the fear I would feel. I try to imagine what my concerns would be.

I do everything in my power to be able to answer the questions the family has. I make sure I have time to listen. I make sure I am completely honest. I try to keep my personal feelings out of the conversation. This is about this patient. Sometimes acknowledging the reality of the situation is the most important act I can do.

The conversation about goals of care is difficult for many healthcare providers. For some of us, especially early in our careers, it can feel like a personal failure when our patients do not survive. The crux of the situation is that everyone will die someday. Perhaps the best thing we can do is offer dignity and peace when death is looming. Comfort measures does not mean giving up. Dying is a natural part of life. We should feel lucky we have the tools to help ease suffering.

Some call it professional development…


Some people call learning how to communicate more effectively professional development. Really, if you think about it hard enough, it is growing up and learning to be a decent human being who thinks of someone besides themselves from time to time.

I am at a loss for words when I see grown educated people who are unable to carry on a decent conversation in the work place. (Keep in mind, I used to struggle with this a lot more than I do now. Actually, it was not that long ago.) Looking back, I think some of my bad behavior was reactionary, or at worst, retaliatory in nature. Unfortunately, I cannot speak to you like you are scum just because we are not BFFs. I have to communicate in a civil manner. It would not be the end of the world if I were friendly even. When you see someone sitting in front of you, say “Hello.” Or, Hallo! If you want to quote my favorite worm. You see these people every day. Be nice. Find some damn common ground. It cannot be that difficult. 

I am often confused when people tell me someone is intimidated by me. Although, my apparent Resting Bitch Face does not help. I do not mean to be intimidating. Actually, if you get to know me you will find I am actually quite riddled with self-doubt and really want to be nice and friendly to everyone. I also assume (apparently also in error) you know all the same stuff I do. I figure you read the same things I read and you have the same innate curiosity. This is not my fault. I do not mean to wonder “why” all the time. I can’t help it. I want to understand.

When I speak to you in a direct and polite tone to inquire about a patient’s condition, you do not get to ignore me or refuse to answer my questions. The same goes for me. If you ask me a question or want to tell me something, I don’t get to refuse to acknowledge you. Sorry, that is not the way adult life works. More importantly, it is not the way professionals behave. Let’s take this out of health care. What if a teacher refused to acknowledge a child or parent who was speaking to them? What if a lawyer refused to speak to the bailiff? We are all adults. You don’t have to be buddies with someone in order to speak to them. It’s your JOB!

I have noticed certain behavior tends to lead to a higher likelihood of possible promotion within any business. You have to be able to get along with all kinds of people. Now, what do you do when you really don’t want to? Perhaps they have done something to insult you. Maybe you just don’t like the pants they wear. It turns out, you have to continue to be nice.

You cannot under any circumstances yell out across the room and demand to know the source of their douchebaggery. Don’t worry, I did not actually do that. (at least not recently.) I only considered it for a few moments. You cannot point out all the ways they have pissed you off. You cannot spell out how wrong they are about what ever topics you believe they are wrong about. You cannot stomp your feet and throw a fit. You have to be nice. Watch your tone. Don’t get defensive or offensive. Stay neutral.

It is hard. Sometimes your inner 12-year-old comes flying to the front of your brain, and it takes every thing you have to hold her at bay. Trust me, this is best.

Throwing a fit or retaliating will only lead to further breakdown in communication. In light of your desire to promote good patient care, you cannot afford to hamper effective communication in any way. So, you ignore your pride. You don’t let your fragile feelings be hurt. You know how to do the right thing. Just be nice. Dammit.

Daddy Issues Part III: Steve Jobs


Steve Jobs was not a very popular movie. My son did not particularly like it. I loved it. This is probably due to my persistent romanticizing of any father figure who attempts, however awkward and clumsy, to connect with their daughter. Steve Jobs was not a good parent to his first child. I am left with the impression that he worked to rectify the relationship in his own way, and I loved it. Jobs certainly had issues. I am not sure I would have liked him, okay that’s a lie, I am completely drawn to people like him. He was portrayed both as brutally demanding and fiercely protective of his people. I relate to this. I am often passionate about my beliefs to the point I get a little excitable. It is a bit of a flaw of mine. I am admittedly a little jealous of those people who manage to stay cool and collected all the time. How do they do that??? Secretly, I bet they have skeletons in the closet. Maybe even real ones. People should get worked up about stuff sometimes. It is what makes us human. Dispassionate people scare me. Seriously. However, they seem to be more productive than the erratic ones. That topic is too big for Daddy Issues. 

I was also interested by the way Sorkin and Boyle handled the relationship with John Scully. John Scully addressed his relationship with Jobs in 2013 at the Forbes Global CEO Conference. You can watch the video here. I was struck by the amount of regret he still carries in regards to the relationship with his former friend. More importantly, I was impressed by his dedication to being a mentor. There were several times the movie alluded to Scully and Jobs having a father- son relationship. So, essentially John Scully was Steve Job’s Work Daddy. I tend to think most of us need one. At least I do.

My relationships with my former work parents remain strong. I still turn to them for professional advice and guidance. I still rely on their opinion and expertise to help me make good decisions about my future. I am sure they find this exhausting at times, especially since there have been so many potential jobs. I hope I adequately convey my appreciation. I really do understand it is an investment in their time and energy. 

I have been extraordinarily lucky to have the relationships I do with some of the most intelligent people I know. They have constantly supported me through my professional career, and it has been a bumpy ride at times. My work parents have taken the time to teach me lessons and to help me grow as a professional, they have counseled me and offered advice, and they have used lessons they have learned to illustrate how they understand my struggles. They never left me hollow and inadequate, they taught me. Just like good parents teach their children. Hence, work parents. (I know, TG says grown ups just have mentors. I have both!) 

So, as I continue on this interesting quest for adventure, professional fulfillment, and possibly even enlightenment, I must remember to keep an eye out for people who have something to teach. I continue to be amazed when I meet someone new who likes to impart information and experience.  It is even better when they take the time to help me learn how to apply it to my personal and professional growth. People come into our lives, and if we pay attention we just might get lucky enough to benefit from their experiences.

These relationships require a level of vulnerability that can be intimidating for some people. It is hard to allow someone to see your insecurities and faults. It takes humility to allow someone to judge your actions. You cannot allow someone offering you guidance to hurt your feelings. You have to leave your pride out of the equation. This is hard at times. I found myself wanting to defend my actions. Sometimes, it was not even the point I was necessarily wrong, it was just there was a better way to handle situations in the future. It is all about growth and progress. Growing pains hurt.

I still miss my old job. I miss having people I knew and trusted available at a moment’s notice. I am having to learn to operate in foreign environments and I do not always have all the information I would have readily available. I know much more about the EMR there. I know my nurses there. I know all the other physicians. It does make a difference. However, I keep telling myself this is a great opportunity to learn. I am learning so many new things. I can’t wait to see what I learn next. So, while this job is in some ways infinitely more difficult, I get to become a better Nurse Practitioner. This is only going to improve the care I am able to provide. So, I will struggle on and deal with the stress. It will be worth it. I hope. steve-jobs-movie-poster-800px-800x1259