Archive for February, 2010

Health care reform according to Gordon

February 28, 2010

Democratize medical education

Then insurance deregulation

            Then slowly with torts

            That clog up the courts

And raise tobacco taxation

 

Frequently people ask me what I think of health care reform.  I give my ideas.  Most people don’t want to hear what I have to say, declaring “We have to do something!” without realizing that the situation can be made worse.

Here’s what I think we should do, and for the most part these are not my ideas.

Reform medical education.  As a wonderful article in JAMA (Journal of the American Medical Association) pointed out, the current premedical sequence wastes two years, mostly to weed out the field because too many people want to be doctors.  At a time when we’re going to need a lot more doctors we shouldn’t be discouraging potential candidates.  If we need to weed them out, let’s democratize the first two years of medical school, which are the classroom years.  Put the content online, and let everyone who can pass Part One of the Boards apply for positions in the clinical years.   Those who don’t learn well from online courses could pay existing or specialty educational institutions.  The current educational sequence (four years undergraduate, four years medical school) could be shortened to four years undergrad followed by five semesters of clinical teaching.  You would need to have more medical schools and you would need to have more residency slots.  The resulting doctors would be willing to work for less money, but they would not want to work as many hours.  Which is OK, because there would be less burnout.   

A lot of people starting the sequence wouldn’t go on to clinical training.  They would be an asset to society on a lot of levels.

Reform the tort claims system.   The medical malpractice industry is alive and growing, and sucking time and money from the health care system.  Money that should be used to cure and heal is being used to pay plaintiff lawyers, defense lawyers, judges, and insurance premiums.  The vast majority of medical malpractice suits filed are dropped, but not before the doctor has lost a week of production, on average.  Lawyers currently name every doctor associated with the case with impunity, hoping that each one will settle for a nuisance amount.  I saw a case where the doctor performing the autopsy was sued (I’m not exaggerating). 

Lawyers need to have the same degree of accountability that they demand of everyone else.  While they get sued all the time now, they don’t get sued for very much.

But the change needs to be slow.

Health insurance needs to be health insurance.  My friend, Mike Bernstein, gets credit for this idea.  Car insurance doesn’t cover gas, oil, or spark plugs.  Home insurance doesn’t cover vacuuming the carpets.  Health insurance should be catastrophic coverage.  Instead of putting the money into the pocket of the insurance company to pay for things like bronchitis and athlete’s foot, we should have Medical Savings Accounts paid for with pre-tax dollars  and earn interest; the funds should carry over from one year to the next, and could be used for anything health related.  If you wanted to, you could use it for cosmetic surgery or gym memberships.  Such a plan would bring the idea of ownership of health and health care back to the individual, which would improve the influence of market forces in medicine.

Raise tobacco taxes.  Every year at the federal level, cigarette taxes should be raised by a dollar a pack per year.  Wait, you say, such a tax is unfairly imposed on those least able to afford it.  Yes, I say, and it should.  Because if you can’t afford your health care, you shouldn’t be smoking in the first place.  As a society we can’t keep pouring money into the largest single cause of death and disability.  The money we raise could go to pensioning off the oldest five or ten percent of the tobacco farmers, per year.

The Libertarians will scream Slippery Slope, if you do that to tobacco, what next?  My answer would be alcohol.  Or maybe high fructose corn sweetener. 

I can’t decide which.

Testosterone deficiency, exit strategies, excellent lunch, saxophone lessons, the VA, and previous careers

February 26, 2010

 

In any human environment

There is a final  requirement

            Wherever you go

            Whomever you know

You face an eventual retirement

 

A very long time ago I had a career in radio.  At the time it seemed a long career, now, from the perspective of 23 years at one gig, it seems very brief indeed.  I learned an immense amount about human communication and those lessons have helped ever since. 

I start Thursdays with a brief radio segment.  On the way to the station I drop a friend at Same Day Surgery, then I drive through the darkness and the ice in unforgiving frigid temperatures, the city just starting to wake up.  In the four-minute wind up, Sean, the DJ and I talk about what we’re going to talk about.

I had intended to speak about skin cancer, Sean would prefer to talk about rapid weight loss.

Sean is a real pro.  The control boards bear a superficial resemblance to the analog stuff I used to work with, but there are no turntables or tape decks.  There are computers with digital music, spots, and features.  News and weather are still read live.

On the air, I launch into my spiel about not losing more than a kilo a week if you really want the pounds to leave and not come back.  Sean notes that I’ve been losing weight, I admit I’ve been hitting the gym pretty hard, and he says that he’s been losing six pounds a week.  I finish with my tag line, “Nicotine, caffeine, alcohol, diet, exercise, sleep, and seatbelts.”

It’s the seven word distillation of the good advice I give out through most of my day.  I probably reach more people and do more good in the five minutes a week of my radio spot than in the rest of my work week.

Then into the cold and a sixteen block drive up the street to St. Luke’s.  My OB patient’s anemia reached an equilibrium at Bad but not Critical.  She won’t need transfusion.  I examine the baby, I give advice about iron intake, and I hang on the verge of giving a discharge order when the nurse notes a fever.  We’ll wait another eight hours to see how she does.

I’ll be giving advice on anemia for the rest of the day.

In the doctor’s lounge I eat an orange and I read the funnies, and one of the subspecialists walks in. 

He’s heard about my career move, and we sit and we talk. 

Bad sleep has battered his face, but I don’t say anything.  I have been sleeping poorly for the last fifty years or so and it’s been worse for the last four weeks.  Doctors don’t mention the bad sleep that they see on a colleague’s faces because it’s less interesting than the weather.  It is always there, a feature of the landscape like the sidewalks, taken for granted.  Occasionally I’ll see a doc who slept well the night before and I’ll mention it as a compliment.

We discuss retirement in general.  I say I know I’ve got to slow down, and slowing down is going to be easier and less of a shock to my system when at sixty than at sixty-five.  He tells me he’s stuck in a rut.  Certainly, in terms of his situation and specialty he can’t slow down.  Not on a personal basis and not in terms of the critical place he has in Sioux City medicine.  We agree that slowing down is a good and desirable goal, and we agree that it can be very difficult.

No two doctors have exactly the same job, even in the same specialty or lack of specialty, even if they work side by side in the same office.  Each one has a unique situation.  In our discussions I take care to make statements about my place in the grand scheme of things. 

We also talk about how Ken Tjeerdsma’s death affected the entire medical community.

He was a very good, very warm cardiologist.  He died suddenly in October at the age of 53 and his passing left a palpable void in the Sioux City medical community.  Every doctor in town knew him and enjoyed him and the tragedy made a lot of us reassess our personal direction in life.  I talk about how it played a large factor in my decision.

At the house I start making calls, talking to recruiters, trying to line up work for the coming year.  I leave some voice mails.

At 9:30 I go for my annual VA appointment with Dr. Sly

Dave Sly has been in town for more than fifteen years.  He joined the VA about 8 years ago.  I talk about my career move.  He’s very supportive.  We talk about what is sustainable in a medical career and what isn’t.  He really enjoys his position and doesn’t have plans to change at all.  We agree we have the best job in the world, but we have problems setting limits on it.

Last year he talked about his move to the VA and how he made the pleasant transition to not carrying a beeper.  That conversation left its impression on me. 

I’ve been thinking about exit strategies for years, especially when things don’t go quite right or when things go too long.  We talk about how much we love the work and how medicine can frequently be too much of a good thing.  Dr. Sly has a career that’s sustainable for a very long time. 

Sioux City has sent a large number of really good FP’s into the VA system.  Enthusiastic about their work, they do reasonable hours at a reasonable pace for a reasonable wage with great benefits.

I’ve considered the option, but I think I’ll do my best for society in a spot where I can use my Spanish.

He examines me.  We go over my lab work.

Niacin and fish oil control my cholesterol, my thyroid words well, and my kidney function continues to improve.

My low testosterone explains the hot flashes, sleep disturbance, and the tendency to tendonitis with resistance exercise.  I’m hoping it helps with my cold intolerance.

In the late morning Bethany and I go down to the bicycle shop.

My career in bike repair ran longer than my career in radio, and the two overlapped.  We look over the bikes in the shop, Bethany picks one out, we talk about modifications and we negotiate a price.

The owner of the bike shop looks like he’s enjoying business so much he doesn’t want to retire.

Prices of bicycles in absolute terms have not gone up much but the quality has spiraled upwards. A 21 pound machine would have cost upwards of a thousand dollars back then, today a 20 pound cycle is available for $450.

We lunch across town at the new restaurant, Eldon’s.  We run into friends, and an acquaintance introduces the owner himself, Eldon.

He is much more down to earth and accessible than I thought possible.  He has done well for himself in the food industry with some brilliant patents.  He looks like he’s enjoying himself in this next part in his career.

We lunch on rib eye sandwiches and fingerling potatoes.  The attention to the science of cooking astounds me.

The food is fabulous, the décor is excellent, and the service extraordinary.  The prices are reasonable.  If this place reflects Eldon, I’d like to get to know Eldon better.  And in a town like Sioux City, it’s very possible to do so.

Bethany drops me at my saxophone lesson. 

I had a very short career as a professional musician.  I wasn’t very good at it, and I didn’t retire gracefully.  That was before I thought about medicine.  I still love music and I still love playing the sax, but I hold no illusions about reinventing myself into the industry.

My teacher loves music, teaching, and teaching music too much to stop teaching music, and does a good slow-down business in the private lesson sector.  She has been a friend of the family for years. 

I bring a gift, a jar of home-made peach jam.

It’s good to play the saxophone again.  It’s good to have formal music teaching now. I like learning some of the fine points that I was never taught, because I was self-taught.  I run through scales and I don’t resent them. 

I have neglected my drive for music, and I look forward to nurturing it again.  I don’t care if I lack the talent to get paid for it.

Telling my patients goodbye, lessons from old doctors and lessons to new ones.

February 24, 2010

 

I have started saying good bye. 

My patients are asking me why.

            I say with a smile,      

            A year’s just a while

But I hear the tears and the sighs.

I have ninety-one days left on my familiar ground.

On rounds at the hospital I run into a new family practitioner.  He looks awfully young, probably because I’m pushing sixty.  He wears a nice suit.  I welcome him to Sioux City, ask where he’s from and what he does for fun.  I tell him to keep playing guitar, he doesn’t know it but someday it will be important.

The patient I delivered last night and her daughter are doing well. 

Morning clinic starts half an hour late, a frustrating experience.  I don’t know that late starts have a cure, and they always put the session into a rush. 

Of course for the rest of the session the patients grow more and more impatient, and deservedly so.

Ninety-one days hence will be my last day, and I explain to my patients that their three-month follow-up will most likely be with someone else.  They ask me whom I recommend.

The best doctor in the world can’t please everyone.  Each one of us in the clinic have our strengths and our weaknesses.  I take a lot of time with each patient, I go into problems in depth, and I have a sense of humor.  Each one of those characteristics has driven patients away and brought patients in.

Some of the patients struggle to hold back tears.

One nonagenarian remarks that the doctors keep leaving, and lists them.

One of those retired well, he’s still alive and active.  He shoots frequently at the gun club and he has had a remarkable photographic career.  He was a good example, he retired bit by bit.  He frequented the doctor’s lounge for a long time and he always had a good joke.  He shines as a positive lesson.

A young couple comes in with their one-year-old for a well child check.  They have blossomed with parenthood as individuals and as a couple.  The complicated pregnancy produced a baby with normal growth and development.  They receive the new of my departure with little surprise.  I will miss them, miss seeing the rest of the soap opera unfold, miss seeing a family grow well.

When I leave, each one of these patients will be a loss, greater or smaller, for me.

Five patients come in to discuss their lab results and talk about choices of treatment.  The problems include B12 deficiency, testosterone deficiency, high cholesterol, low thyroid, high thyroid, vitamin D deficiency, and hepatitis C.  I enjoy saying to a patient, “We can make you feel better,” and mean it.

At five I start working on messages.  At five-thirty I get a beep from the Hospice nurse.  She asks me about an order for an antibiotic I gave an hour before.  I allow as how I didn’t give the order, it couldn’t have been me, but it sounds like the right thing to do, and if the patient can’t take the pills, liquid will do.  After I hang up I confirm with my nurse that no, in fact, we didn’t take that call.

My cancer removed, reflections on being a male in OB, a frightening delivery

February 24, 2010

I hope I don’t see it again

Red rivers with nary a pain.

            An expert you’ll need

            When the postpartum bleed

Comes from placenta that’s been retained

My anesthetic, being strictly local, doesn’t interfere with me cracking jokes during my surgery.  The prep was more painful than the needles and Novacaine, but I don’t know why the squamous cell carcinoma growing on my forehead for the last couple of months would be tender.  But it is, and the scrubbing hurts.  I keep my eyes shut and I tell a few warm up jokes to the nurse prepping me. 

The plastic surgeon, Dr. Paula Formosa, has a great sense of humor and when I’m not telling jokes (It was so cold I saw a lawyer with his hands in his own pockets…) she gives me a running commentary.

We wait for the Roger, the pathologist to read the frozen section and say whether or not the entire tumor has been removed, and I tell a long involved joke about Navajos, sheep, dogs, and tourists.  Right after the punch line I hear the door open and the pathologist’s voice comes through announcing a good, clean removal.

Roger and I went archery elk hunting in western Colorado in 1989, along with a dermatologist (since deceased) and Dolf.  Roger and I both brought home bull elk, and I got a deer as well.  We’ve been friends for a very long time.  He offers to buy back the flint lock muzzleloader pieces he sold me 18 years ago that I haven’t turned into a functioning firearm, yet. 

While Dr. Formosa finishes the wound closure I listen to the nurses talking, and just before she lifts the surgical drapes from my face I declaim a limerick that starts, “There once was nurse named Michelle…”  It’s not my best work, even though it took me more than three minutes to put it together, but it is so unexpected and both in and out of context that the laughter paralyzes the OR for about a minute.

In the recovery room I call St. Luke’s Labor and Delivery.  My patient went into labor as I was on my way to my surgery, and when I call she has dilated to about 5 centimeters. About three in the afternoon, Bethany drops me off at the hospital and I take the back stairs up to OB.  I change clothes and I check my patient, rupturing the membranes and placing a scalp electrode.

Then I go down to the doctors’ lounge in the basement to search for food.  With nothing in my stomach since last night, I settle for a soggy chicken salad sandwich and a marginal apple and find them delicious.  I go online and check lab results and scanned documents.

The irony doesn’t escape me that I’m cramming more into an hour than any sixty minutes deserve at a time in my life when I’ve decided to slow down.

Still famished I return to second floor to raid the OB kitchen for a bag of chips and two oranges, and I retire to the doctors’ room.

Very late in my obstetrical career I learned about non interference.  The nurses call it “laboring down,” it’s a trendy concept.  I think of it as Not Interfering With The Flow Of Feminine Energy. My part of the process involves not going in to see the patient between the time I arrive to greet until she’s very close to delivering.

That I, a male, would have anything to do with labor and delivery is an accident of history.  The era of men in obstetrics, an exclusively European phenomenon in the last 500 years, is rapidly drawing to a close.  Most OB residencies sport no more than a token numbers of Y chromosomes.  I have been privileged to see a part of the human condition that very few men in the course of human existence have seen.  Each delivery is a thrill.

It’s also like riding a rollercoaster without a grab bar.

Every half hour or so I walk from the television twenty three steps to the nurses’ station to make sure nothing is passing me by.  In between times I doze and flip through the channels and ice my incision with a closed can of Sierra Mist.

It’s the worst TV set in the entire hospital and has no remote control, and the room is ten degrees cooler than the hallway.  I start to shiver and I get up and prop the door open with a chair.

About seven the secretary sticks her head in and says, “Dr. Gordon, they need you immediately.”  This time I sprint down the hallway.  The baby’s head has delivered, and I put on gloves, clear the front shoulder, then the back shoulder, and the baby slides right out.  I suction the baby’s mouth and nose, clamp and cut the cord. The nurse assures me that not ten minutes ago the cervix was still 8 centimeters. 

The baby does well, a sense of rightness and completeness envelops the room.  I have been privileged to be a part of this unique island of peace for more than three decades. 

Twenty minutes later the placenta delivers slowly, stubbornly, and it exits asymmetrically.

Then the bleeding starts.  Brisk, dark red uterine blood flows at a frightening rate. Not my first postpartum hemorrhage, I ask for one of the nurses to start Pitocin.  The bleeding slows.

It starts again.  I use two hands to massage the uterus, one outside and one inside.  The bleeding stops.

Then it starts again.

Further uterine massage does no good.  I ask for Methergine, for the second time in my life. 

It helps for less than a minute, but the blood pressure comes up.

I ask for help.

Obstestrician from group A in fact is on the OB floor, but he’s doing a C section, and won’t be available soon.  Obstetrician from group B is on call for the other group, and I ask that she be called.  By phone she suggests Hemabate.

Hemabate came into the armamentarium twenty years ago but I haven’t needed it in all that time. 

It doesn’t help.

The patient feels OK, she’s not dizzy, and there’s no pain at all.  I calmly tell her she’s bleeding a lot more than usual and that I’ve called a specialist, as I watch her life force drain steadily out.  Fear grips me, the rollercoaster without the grab bar.

I ask for two units of blood to be typed and cross matched, and I remember why, when I was in New Mexico, our hospital wouldn’t start an OB program if we didn’t have a blood bank.

By cell phone, the obstetrician asks for 1000 micrograms of Cytotec to be given per rectum.  Which I do, then I change gloves.

Obstetrician from group B comes strides in smiling. I relax as the cavalry, Marines, Angelina Jolie  and John Wayne arrive.  With fluid economy of motion, she takes a surgical gown and a pair of gloves from the cart, and slips them on.  Less than fifteen seconds after her entrance she is ready to go.  I stand aside, and she slides her hand right to the problem area.

She turns to me and in a voice I can hear but no one else can she says, “Yeah, it’s retained placenta.  You know in residency they used to call me Roto Rooter.”  I wish there would be a more graceful nickname for someone who performs the task at hand with such grace under pressure.  I admire her work.  She saves the patient’s life with style and professionalism.  With a few deft swipes of the fingers, she removes the pieces of afterbirth stuck inside the womb, and when she removes her hand, the bleeding has stopped.

I have no doubt that in a non industrial society the patient would have died.

I started delivering babies in 1977 and in all that time I have never seen a case of post partum hemorrhage caused by retained placental products.

The patient has been a Woman of Steel, tolerating an immense amount of pain with  no chemical relief.

We explain to the patient that she’ll need to go under anesthesia to have the uterus thoroughly scraped.  She asks if she can have her tubes tied at the same time. 

Then the embarrassment starts.  The patient had spoken to group A before delivery regarding sterilization, but I called group B when I was in a crunch. 

I step out to the nurses’ station with Obstetrican from group A, to find Obstetrician from group B just done with his C section, and they discuss the situation.

The situation is thoroughly my fault, and nobody has gotten mad at me.  In fact, they’re downright civilized about it.  While the two obstetricians dialogue back and forth I marvel at how docs from competing groups cooperate.

The Sioux City medical community is a hotbed of functionality.  We waste less than two percent of our time and energy in backbiting and politicking.  Our turf wars are time limited and don’t bring about deep rifts.  If Dr. X has a beef with Dr. Y and either tries to bring in Dr. Z, there will be a notable lack of recruitment.

The two consultants collaborate on a regular basis.  When they’ve finished not being territorial about who does what procedure, Obstetrician from group A and I talk about how wonderful life is without infighting.  She thinks it’s because everyone has plenty of work. I think it’s because the larger community works hard at getting along. 

While we wait for the OB operating room to be readied after the caesarean section, I go to the nursery and examine the baby.  She sleeps peacefully under the warmer, and the grandparents, aunts, sister and cousins watch through the chicken wire glass.  The little girl has been born into a large, warm, caring family.

I come back to the surgery area and I watch the consultant clean the inside of the patient’s womb under general anesthesia. 

I change back into street clothes and meet Bethany in the lobby.  The incision is aching and my back hurts, I can tell it’s been almost three weeks since my Enbrel or my omega 3 fish oils. 

When I get home, I start to write, and my friend and college buddy Bob calls from California.  He has been a good sounding board for my writing.  We talk about how life is going for both of us.  It’s very late when we ring off.

Neither one of us is sleeping well.

Migraines, time management, bolting lunch, and saying NO.

February 22, 2010

Abnormals I like to see

Thyroids, B12s and Vitamin D

            I view with compunction       

            High liver functions.

I just hate hepatitis C.

 

One of my medical school classmates said, in 1978, that he didn’t want to go into primary care because he didn’t want to just take care of sore throats and runny noses.

Just before bed last night I logged onto the lab queue.  Six patients blinked in red from the icon at the lower right corner.  A seventh blinked in black.

 Vitamin D deficiency is rampant, and of the six patients with abnormal results, five had low Vitamin D levels, one critically low at 7.5, the lower limit of normal being 33.  One set of lab values gave a new diagnosis of rheumatoid arthritis, another a case of hepatitis C.

I see so many people who just don’t feel good that twelve years ago I specified a group of lab tests: CBC, sedimentation rate, B12/folate, thyroid, Chemistry 14, and hepatitis C; I named the panel the GFMP (Gordon’s fatigue and malaise profile).  I put it together right after I’d gotten a lot of propaganda from the Hepatitis C Foundation.  Three years ago I started checking Vitamin D levels.  In all that time I picked up exactly two cases of hepatitis C, and both of them were found by sleuthing down abnormal liver function tests.  In this new case, the liver functions were normal, along with the rest of the panel.

Of historical note is that hepatitis C didn’t even get identified till after I’d finished residency.  There was nothing to do about it for years; now we’re running a 50% cure rate, cutting into the number of people needing transplants.

I sent emails to the phone nurse pool, to be opened up in the morning; get viral load and viral type on the Hepatitis C, send the rheumatoid patients’ lab work to the rheumatologist, and start all those Vitamin D deficieny patients on bold doses of the sunshine vitamin. 

I get a call at about 9:30 AM from a hunting buddy who is connected to me at least three ways.  A friend of his has bad migraines and isn’t getting very far with the other docs and would I be willing to work the friend in?

I ignore the fact that I have had bad consequences because I don’t say No well, and I say yes.

I find a hole in my schedule at 11:30, and I tell my nurse.

Three other holes that don’t exist get filled before 11:30 and I don’t start with the new patient till 12:20.

Ninety percent of my migraine patients get successfully managed with life style modification.  For all you migraine sufferers out there, here goes:  Eliminate nicotine, caffeine, alcohol, Nutrasweet, cheese, and hotdogs.  Get into a rigid, effective sleep pattern.  By the time I individualize details for this migraine patient (for example, move the TV out of the bedroom, quit smoking with Chantix, and taper down the caffeine) it is ten minutes to one, when the afternoon patients start up, and my documentation is 12 charts behind.

Oh, yeah, and I arrange an MRI for her because she’d never had one and her headaches are getting worse.

I bolt my lunch in five minutes and I’m hacking away at my computer, putting in documentation.

Eventually I hope to get control of my schedule, but I know that it won’t happen till I start saying No.

I’ve gotten better.  Four times today when patients tried to put more than four problems on their list I gently made them put together a realistic agenda, and encouraged them to come back at a later time.  I didn’t tell them how trying to pour gallons into teacups strains me, puts me behind so the other patients get mad.  I just said boy, that’s too much for one day, but it’s really important, can you come back Tuesday?

I still fall into unrealistic time management thinking more than once a day. 

I still finish with a joke.

A wrist, a splint, no xrays. Yet

February 21, 2010

A fellow on the friends’ list,

Gave a call, and here is the gist:

     “I have this pain

     I’m sure it’s a sprain,

I know I didn’t fracture my wrist.”

The call comes at quarter past eight from a friend who knows me well enough that not only does he know I have wrist immobilizers for each side, but he probably knows where I keep them.  He fell from his horse yesterday, he has been icing and elevating, but it hurts like the dickens.  He’d like to borrow the splints.

Five years ago our Tae Kwon Do instructor suffered a serious case of testosterone toxicity one evening, and we did push ups till we could do no more.  Tendonitis followed shortly thereafter, and I’ve never thrown away the wrist immobilizers.

My friend is absolutely positive it’s not broken because he has great range of motion.  I’m not so sure.

He knows my Sunday schedule, and knows where to meet me.  I’ve not seen a sprained wrist in this particular anatomic location, my fingers push and probe and I determine that the anatomic snuffbox (the hollow at the base of the thumb) isn’t tender.  I have ruled out the worst wrist fracture.  Despite his assurances, the wrist doesn’t move well, and the swelling is obvious.

I loan him the splint, slipping it on and velcro’ing it in place, and I watch relief play across his face.

Because I know him so well, I can rely on him to show up to the office tomorrow morning to get xrays.  It’s a relief to him to bypass ER and Urgent Care, and to take care of it on a flexible basis.  For my part, I’ve taken a history, and done as much physical as is needed; the only piece of the puzzle I’m missing is the xray.  He can come in tomorrow on his schedule, get the xrays taken, and I can review them at my leisure.

I enjoy doing stuff like this with my friends.

Late in the day, after a good long workout and a short nap, Bethany and I stop by the grocery store for a bottle of wine; we’re going to dinner at the house of another set of friends.

I drink very little, I know nothing about wine, but I’ve decided on a price.  I snatch a bottle of Simi from the shelf.  Later I will find out I made a good choice.

In the checkout line I stand behind a retired doctor.  I recognize him, he doesn’t recognize me.  He moves unsteadily as he buys his four large bottles of vodka, and I see hopelessness and hangover smeared across his face.  I smell the alcohol on his breath though I stand at arm’s length.  I remember when he retired.

If a person chooses to believe in signs, he can see signs of whatever he wants wherever he looks.  Still, it is difficult for me to ignore what I’ve just seen.  I don’t want to end up like that.  Even if it doesn’t involve alcohol, I don’t want to see out my last years with that kind of despair.  Clearly, I have to slow down my pace of work and I have to have something to fill the void.

Something new every day, great food, retirement plans

February 21, 2010

Eventually I hope to grow wise

Every day still holds a surprise

            I note with precision 

            When I did circumcision

A newborn with tears in his eyes

When a doctor sees a hospital patient with no intention of dictating a note or sending a bill, he or she calls it “social rounds”.  Doctors do it a lot but we do it less and less as the years go on.  Hospitalists do much of the hospital care.  Only in the USA do outpatient doctors also do inpatient medicine.  Bethany and I stop up to see a friend at St. Luke’s, and we sit with him about 45 minutes till he is ready to go back to bed.  I stash Bethany in the doctors’ lounge and I go back up to newborn nursery.

I called ahead to make sure the baby would be there at the right time, so, of course, he isn’t.  I look over the chart and there is no circumcision permit signed, so I grab a stethoscope and I go examine the mother, who is doing very well.  I confirm that she wants the baby circumcised, I go over the consent form with her, and I go back to the nursery.  I examine the baby, then I have the nurse get him ready for the procedure.

Babies hate cold and they hate being tied down, and they cry during the circumcision.  In fact, they cry before the procedure.  This one is no exception.

What is exceptional is that he has tears.

Newborns cry, but children usually don’t make tears till they’re at least six weeks old. 

I graduated medical school in 1979 and I started seeing patients in 1977, and I have seen thousands of newborns.  Today is the first time I saw a one day old infant with tears.

I have a very long memory and I’ve seen a lot of patients and if it’s a day with patients I will see at least one thing I’ve never seen before.  Especially my clinical afternoons are strange.  Sometimes things get so weird that I don’t even believe them.  I used to say, “This afternoon couldn’t get any stranger unless Elvis himself actually showed up.”  I don’t say it anymore, I’m afraid it will happen.  Many of those things I will not write about because I can’t write about them without breaking confidentiality and because I will not be believed.

After the circumcision I dictate my notes, order a bilirubin for the slightly jaundiced baby, and ride the elitist, Doctor Only elevator down to the doctor’s lounge.

Twenty two years ago before I was betrayed successively by my back and my ankle I didn’t use the elevators because they were too slow.  Of course the doctor parked much closer to the patient back then.  Rounds were quicker because the minimum time investment was smaller.  As time has gone on the architectural distance between doctor and patient has steadily grown (this is a nationwide trend).  During the same interval, doctors going to hospitals spend more time in hospitals and less time in offices or clinics. 

Back when I started taking elevators, I eschewed the one reserved for docs as being elitist.  I have since embraced it, and I have come to cherish the time I spend waiting for and riding in elevators as being some of the few quiet moments of my day.  I don’t even try to multitask in them any more.

Bethany is watching a crime show on TV when I walk in.  We talk for a short time, then we drive to South Sioux City to meet a colleague for supper.

I have to wrap my colleague in mystery because the career plans we discuss are not yet public knowledge, I will not even reveal gender.

It is neither secret nor surprise that I know every doctor in Sioux City.  It would not be out of the ordinary to sit down with any of them to have this talk we have planned.

The colleague wants to move someplace warmer and sunnier.  I agree that such things are desirable, but my non medical social contacts have become a part of who I am, my social world; my career plans don’t include moving.  The colleague talks about an offer, the details of which have not been firmed up, for about half the current gross income.  We discuss how to figure cash value of perks.  We talk about state and federal income tax.

We also discuss the concept of marginal cost benefit.  Taxes have become an disincentive to work, we agree.  I talk about some of the offers I’ve seen which would cut my work time by half but give me 80% of my disposable income.

We talk about the owner/employee tradeoffs.  We agree we want to have more time, that as we age the time becomes more important than the money, that working for a long time is desirable, and that most doctors work at unsustainable paces. 

The food is exquisite.  The company is wonderful, the conversation clear, and the pace at which we eat is leisurely.

Thirty years ago during residency, I learned that, if you’re in medicine, there are three things you should do every time you get the chance, because you don’t know when you’re going to get the chance again: eat, sleep, and pee.  Since then I have gotten very good at bolting my food.  Usually I eat without tasting, a denial of one of the basic pleasures of life.  But tonight I have no trouble eating at a leisurely pace, a wonderful contrast.

We enjoy dining out but the food at home exceeds the quality of most places.  If we travel to small towns we’ll have no trouble having fine dining.

On the way home Bethany notes that the streets are eerily dark, and then we realize that the power is out.  Here and there a few houses show up as islands of light in a sea of darkness.  A few people sit in cars outside their garages, with motors running and headlights glowing.

Most people in Sioux City either don’t lock their front doors or don’t carry a front door key because most people come and go through their garages.  Unusually for us the front is locked, and the garage door opener is powerless. 

I surprise Bethany with my front door key.  We empty the upstairs freezer into a cooler and put the cooler in the snow bank off the front porch.

Without power, I have no connection to the Net, but my laptop obeys my touch and I write till it runs out of juice, while Bethany reads using my LED headlamp. 

Which is why today’s posting is a day late.

I’m not done with OB yet!

February 19, 2010

FEb 19 2010
 
The morning is off to a bad start.
In the wee hours, I received a call about a patient of mine going into labor.  I commented to the nurse that a patient delivering on her due date was bound to happen sooner or later(it would have only been the third time in 31 years).  I tossed and turned till about 530, when I called to find out how the patient was doing, only to find out my partner was in the process of attending the delivery.
In a multisystem series of errors, it seems a nurse assumed I had stopped OB a few months ahead of my official stop date and called my partner.  Yes, there’s more to it than that but the explanations I get from Labor and Delivery have certain logical flaws.
I get apologies but no real indication that things are going to change.
I have had all the disadvantages of doing OB (the vigilance, the constant presence of the beeper, the sleeplesss night) and none of the advantages of doing the delivery (the joy and the continuity of care, the euphoria of being there when new hope and light come into the world).  Sort of having a hangover without getting drunk.
Even though I’ve only three months left in this position, I will be addressing the problems at multi levels today.

Networking

February 19, 2010

Blog 18 February 2010

I said at the Nursing Home meeting,

“I have news of a change that’s proceeding,

            It’s my CLINIC I’m leaving

            So don’t go grieving,

This group I will still be leading.”

 

Twenty-one years ago Congress passed a singularly Byzantine piece of legislation called the Omnibus Budget Reconciliation Act, or OBRA.  Like everything else that our government does, there were good parts and bad parts.

OBRA mandated that all nursing homes receiving Medicare funds have a medical director.  At the time, most of the docs in our office signed on for a medical directorship.  I’m required to attend and sometimes lead a monthly Quality Assurance meeting at a nursing home an 11 minute walk away.  If a new nursing home patient has no doc, I serve as the attending physician.  I make rounds on the patients every two months, and if problems come up in the meantime, they call me.

Driving away from home in the daylight is a real treat.  The parking lot is empty and the air is cold, but I arrive three minutes late and the participants are ready.

None of the staff have the longevity that I have.  I have had some wonderful working relationships with pharmacists, Administrators and Directors of Nursing, but I am the sole continuity character.

We go through the format which I established 21 years ago and which has been modified but little since. 

We have made steady, slow progress in measures of quality of care over the years.  At the first meeting, out of 200 patients, there were 63 falls.  This month, out of 130 patients, there were 9 falls.  Pressure ulcers (what used to be called bedsores) have dropped from 18 to one, and that one was Stage I (by definition, no worse than a red mark).  Infections have improved, so have hospitalizations. 

The death rate continues.  Around the country, nursing home patients are older and sicker than they used to be; my nursing home now has a Hospice wing.

Twenty one years ago, fax machines were expensive, and each nursing home patient generated an average of 2 calls per week.  Eventually I had to limit my nursing home patients to no more than 25 per facility, and at one time I covered three facilities.  Times have changed; our clinic employs a nurse practitioner part time who does a wonderful job of fielding the phone calls before they can reach the doctors.  I have exactly six patients left in one facility.

All docs should do some pro bono work, and for a long time I had several things that I did for free.  I don’t have those any more since those rats at Medicare started paying me decently.

At the end of the meeting I enthusiastically announce my plans for a year of going walkabout.  I assure those present I’ll still be covering the meeting once a month, and I’ll round on the patients every two months (as mandated by OBRA). 

All around, people wish me well.  By phone, the administrator makes the offer of “If there’s anything at all we can do…” so sincerely that I try to think of something.

The sun is shining for the first time in what seems like weeks when I leave the nursing home and wind my way through town to my acupuncturist, a chiropractor.  I’ve watched his hair grey in the last eleven years.  In that time the hostility the MD’s/DO’s held for the chiropractors has faded to a mere fraction of its former blackness. 

I tell him how my stress level is affecting my sleep and why I can’t take my Enbrel for another couple of weeks.  We both know well the vicious cycle of sleep deprivation and pain.  He inserts seventeen needles and I leave feeling better, but my back still hurts.

Next stop is the music store. 

Music at one time was my passion and my life.  I gave it up because of a lack of talent. I’ve turned out to be a vastly better doctor than I was ever going to be a musician.  But in preparation for slowing down I’m taking lessons, and I pick up items I could never have afforded while I was a musician and had time to practice. 

Consider the irony.

It’s a hop, step and jump to the Chinese restaurant, and I meet my friend Steve Chang.  Steve has run the Hunan Palace for about 20 years.  In that time he changed locations three times, and his current location is very close to my next-door neighbor’s (Kent and Michelle) farm.  During deer season, Steve and I occasionally take our muzzleloaders there.  We sit and chat about my slowing down till the noon rush starts, then I finish my (very good) Kung Pao chicken.

I stop by the office to check my messages.  I get several I-wish-you-weren’t-leaving hugs, and one you-are-so-smart-to-do-this hug.

Diane, my saxophone teacher is waiting for me at 1:00 PM.  She taught all three of my daughters when they took band, and is now semi-retired.  As the jazz musicians say, I got no chops; in English that means I haven’t practiced in years so that the muscles in my mouth are weak and lazy and my breath control is terrible.

I am a self taught musician, and a long time ago I figured out that if I wanted to get good at my instrument, I would have to practice.  Of course by then my medical career had taken over my life and there was no time.  And there was no money for things like reeds or music stands. 

My teacher shows me what I’m doing right, gently corrects me about what I’m doing wrong, and demonstrates horn care. 

My dermatologist looks at the sun damage and the skin cancer on my face, and we talk about how to treat things to hopefully prevent more skin cancers.   A knowledgeable man with a strong intellectual sense, for years we have had wonderful discussions about history and some of the better media courses we listened to, but today we briefly talk about my plans for my future.  He congratulates me on my realization that my current pace of work is not sustainable, and my decision to slow down before it becomes a radical change.  He recommends no Aldara for me for another four weeks, till after my surgery.

When I leave his office I realize it’s warm enough to bring my deer blind in.

While I change clothes at home I run into Bethany, she’s on her way from Point A to Point B when we see each other. 

The short drive out Broken Kettle Road is better for the glorious sunshine and the thawing temperatures, but Raul Benegale’s long driveway is now a corridor between two four-and-a-feet tall ice sheets.

Raul is a crackerjack neonatologist who’s been in town about fourteen years.  We sometimes throw yoyo tricks together.  He raises pet Morgan horses on an acreage inside the city limits, and asked me to come see if I could discourage the deer who snack on everything he tries to grow.  I did my best but the bad weather set in early and my blind, a 5×5 pop up tent, was buried in snow before I could actually bring home one of the pesky whitetails.

All over town, my life is part of a web.  I can’t go anywhere without knowing someone, and I can’t do anything without relating it to someone I know.  My patients are my friends, my friends are my patients, my colleagues and I network inside and outside the medical world.

I wouldn’t have it any other way.

Serving notice

February 18, 2010

Resignation letter

17 February 2010

 

I won’t whine about working so late

For I know that the stress will abate.

            Things will get better

            For I turned in the letter,

May 24th is the date

Early in the graying morning I retrace my old steps to Mercy Medical Center to visit the newborn and dismiss her.  When I arrive the doctor’s parking lot is still empty, the lounge is quiet.  The nurses, however, are at shift change and the manic spirit of those about to go home mixes with the optimism of those coming on.  I look north down the main corridor and I point out the beautiful golden morning light staining the walls at the end of the hallway, rays coming horizontally, flush with the wall. 

OB and nursery are on the top floor of the old part of the hospital.  Twenty years ago I came here a good bit, now it’s rare.  I’m trying to get out of the baby delivery business.

I won’t miss Mercy.  A couple of years ago they installed a highly dysfunctional medical records system and a group of cheerleaders to deny that there was anything wrong with it. I’ve done my best to stay out of there ever since. 

Rounding at two hospitals is fabulously inefficient, seeing two patients generally took an hour and a half with more time spent driving than spent face to face with patients.  Our group split the work of the two hospitals about six years ago, so that one doctor would round at one hospital instead of six going to both hospitals, and then we rotated weeks, coming into the office an hour later when we had hospital duties.  Then when both hospitals installed hospitalist programs we could give over almost all of our patients to docs who do nothing else.  We still see our own newborns, they’re the most fun thing in a hospital.

I go down the back stairs, an architectural remnant of the times when people used the stairs a lot, and I read the funnies in the doctors’ lounge while I eat an orange.

The sun is bright when I leave the hospital, a relief to the eyes.

First thing at the office I pick up the dictating machine.  I went through one about every seven years, this one has lasted longer because we don’t dictate with the new system.  I dictate my notice.

It’s not easy to do.  I have to look at a calendar to find the Friday before Memorial Day weekend.  It will be the day before my wife’s birthday.

I carry the recorder back to the transcriptionist.  She’s been working with me for 18 years.  Back in the day, one afternoon my nurse, the transcriptionist, and I went to lunch together, and I found out I could dictate in macros, which saved me about 20 minutes a day.  I still didn’t get out earlier. 

I warn her to get out her Kleenex. 

An hour and a half later she comes in with tear-stained cheeks and hands me four copies, three of which I sign and one of which I casually stash in my desk drawer, a single sheet bringing an end to 22 years of service, almost a quarter century of watching the drama and irony of the human condition in one place.

The day goes long, and I go to the gym when most people go to supper.  I have just worked up a really good sweat when my beeper buzzes on my hip.  Our Urgent Care needs me; they’re backed up.  The doctor on call for the group serves as back up when the regular staffer at Urgent Care is overwhelmed.

For an hour and a half I explain to concerned parents why the child doesn’t need antibiotics, to another patient why he does, and to one other why he really, really needs a CAT scan tonight. 

I get home at 9:30, and I know I should go right to bed, but I start with a limerick and I can’t stop.