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.

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