Archive for August, 2012

Great ice cream and no spoon. I still love the 21st century

August 30, 2012

Going back doesn’t sound like a blast,

Sure, time is moving too fast.

There were things to endure

That now we can cure.

Nostalgia’s a thing of the past.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Doctors tend to suffer from nostalgia.  Many of us express a longing for the good old days when having MD or DO after your name automatically brought you respect, a simpler time, before technology kept butting between the doc and the patient, when government and insurance companies didn’t interfere with clinical decisions.  Sometimes I’ll say to a colleague, “Pick a year, any year, not this one.  When would you rather live and practice?”

Don’t get me wrong.  I resent the second guessing by health care bureaucrats, whether private or public.  Clearly physicians rely too much on MRIs and not enough on physical examination, and the constant fear of a lawsuit detracts from every patient encounter. 

But I don’t want to go back. 

Immunizations have done away with more than 80% of the pediatrics problems leading to hospitalization in 1982, the year I finished residency.  I can now distinguish between a true positive TB skin test and a false positive from a BCG vaccination(given in another country) with a test called IGRA.  Testicular cancer patients now have better than a 90% chance of cure.  PET scanners, more available now than ever before, show up malignancies with incredible accuracy.  Outpatient surgery has become the norm. 

We can cure schistosomiasis and we can treat rheumatoid arthritis.  Cure rate on Hepatitis C has gone  from 10% to 60% in ten years.  We have good, solid drugs for alcoholism and nicotine addiction.  The generic $4 list includes a lot of medications that used to fetch three figures a month.

In addition to the incredible technology and the great pharmaceuticals, we have consultants of unprecedented caliber. 

I’m fond of saying that if you want 1990’s medicine you can have it at 1990’s prices or lower, but you have to pay for the updates.

Our clinic has a contract with a program for the medically indigent.  Briefly, we get $20 per visit for patients who can’t pay for medical care.  If they need services outside the range of primary care, we can send them to fine specialists 4 to 6 hours away.

The program looks great in theory but the execution leaves much to be desired.  Some of those patients have to drive 2 hours to get to me.  Scheduling referral services involves a faceless, glacial bureaucracy. 

The geographic imperative rears its ugly head; a six-hour drive represents a huge barrier to quality care, no matter how great the facilities at the other side of the state.

On the one hand, the drive deters overuse of medical care.  On the other hand, I worry that my patients may suffer lasting harm from treatment delay, that the system offers too many opportunities for the ball to drop.

Twenty-first century medical advances have made medicine an incredible profession, but economic realities present huge frustrations.  Like having the world’s best ice cream and no spoon.

I still wouldn’t want to practice in any other era.

 

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Warnings over coffee

August 26, 2012

I warned the young doctor, the moaner

Striving to pay off his loaner

All of that debt

Just has to be met.

Please, never turn into an owner.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Job offers cross my desk and invade my emails every day.  Most weeks include half a dozen calls from recruiters.  Just last week I got a flyer promising a strong six-figure base pay, with an available 66% upgrade for taking call.

I’m not in the market. Just trying to work reasonable hours takes up most of my time.  I forward some of the more interesting opportunities to a couple of colleagues who find themselves between jobs, a status that doesn’t last long for a doctor.

I sat down with one of them today, over coffee, to talk about an offer.  The email promised half the money a teacher makes, but would give the successful hire a chance to improve some skill sets. 

I informally counsel a good number of docs in the early phases of their careers.  If I talk about hanging up a shingle, I caution about the burdens of being an owner, and none of the cautions relate to the rapidly changing medical business climate.

The Affordable Health Care Act increases the regulatory burden on doctors.  With all the forms to fill out and reports to generate, few physicians can continue in small or solo practices unless they reject money from insurance and the government.  But that’s not what I warn the young docs about.

A medical business owner has to worry about overhead, and thus must be willing to fire less than stellar employees.  Few medicos have business training, even fewer have business sense, and most try to keep marginal staff in place, hoping they’ll improve.  If you’re kind enough to want to help people, you hate to fire a patient because they don’t pay bills.

I apply all these criticisms to myself.  Every day I go to work not worrying about management reminds me of how much emotional energy I spent on being a boss.

On the other hand, I finished med school with a mere $3,000 in debt (I had great poverty skills) and I didn’t face six figures of pay back.

More and more doctors marry other professionals and two good incomes decreases the drive to seek the highest paycheck.  At the same time, the physicians now coming out of training have had work hour limits, and hence have better leisure skills than my generation of doctors.

“Don’t get on the hamster wheel,” I cautioned my colleague.  “You’ll find it very difficult to get off before you burn out.”

Still the 40-hour work week, the ideal balance between home and work, eludes every doctor I know of, even the ones on salary.

The difference between a horse and a mule

August 23, 2012

It’s unnecessary to that much force

To run to the ground a great horse.

So don’t be a fool,

You can stop, like a mule

If your motives come from the source.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Even doctors have to have doctors.

I confirmed my appointment with a subspecialist today at 12:45, and I turned to Bethany.  “He works through his lunch hour,” I said.  “Should I bring him a sandwich or something?”

“I don’t know,” she said, “Are you sure he doesn’t take a late lunch?”

“Yeah, his nurse said he was working through his lunch hour.”

“You can if you want.  But is he working for someone else?”

“No,” I said, “He owns his practice.”

“Well, when you were an owner, you did the same thing.”

Of course she was right.  “That’s the difference between a horse and a mule,” I said.

A horse has a passion to run, I explained, and riding a good horse hard ranks among the great experiences of life.  A mule has none of the fire of a horse, and the best gallop of the best mule deserves the word lackluster; the words plod and mule go well together.  Yet most riders can get a horse to run so far and so fast that the horse dies, hence our term, “ran it into the ground.”  An overloaded mule cannot be induced to move at all.

Give a horse morphine and the horse will run, give the horse an adequate amount of morphine and he’ll run himself to death even without a rider.

I approach analogies between humans and animals with caution.  But making any person, and particularly a doctor, their own boss looks a lot like giving morphine to a horse.  They don’t take enough vacation, they work very long, very productive hours, and they tend to burn out.

I wish going onto salary had made me more like a mule.  As it is, my drive to work destructively long hours has nothing to do with the money but with the action of the job and my commitment to my colleagues.  I do not want to give up the drama and irony of the hospital work, nor the intellectual challenge of having to rub elbows with docs who know more than I do.  Nor do I want to stop being part of the team, going the extra mile to lighten the load of the doctor who comes after me.

The problem comes not from the outpatient hours, but from the people who get desperately ill after hours and on weekends, and from our booming expansion.  My first two weekend calls last year had a total hospital census in the single digits, but our practice now averages seven hospital admissions per twenty-four hours and our hospital census has gone as high as forty-two. 

Yet this last weekend deserves a delicious rating.  I started early, finished rounds in good time, lunched and napped and supped, getting into bed before eleven each night.  I’m running on the same relaxed euphoria that I did a year ago.

The real question is how hard I’ll let myself get worked.

A night not on call

August 14, 2012

When nearing the end of my shift

I get an emotional lift

In the dark or the light

I’ll be at it all night,

What?  No call?  Such a gift!

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

Illness does not respect the clock or the calendar.  This central fact remains an undercurrent in the world of medicine.  Doctors have more visibility during business hours, but when the world goes home for supper, every medical practice must take into account afterhours medical needs.

A solo practitioner takes call all the time unless he or she shares a spot in a call rotation.  A group practice rotates call amongst the members.  Some practice models close in the afternoon, advising patients to call 911 or go to the Emergency Room if they have a medical emergency. 

In the last two years of med school and in the three years of residency, I took call in the hospital.  I learned to pack for an overnight in less time than it took to shower.  Most nights I would snatch minutes (rarely hours) of low quality combat sleep but the work went on all night.

I checked the call schedule last week and found my name for Tuesday. 

We  talk among ourselves about the emotional preparation we do for call, at the Practice Formerly Known As Mine we referred to “having your flak jacket on.” 

We always carry a certain amount of fear of being overwhelmed. We face the possibility that the chaotic distribution of the tasks which must be accomplished will overwhelm our time available to accomplish them.  Or that our emotional resilience to the really tough things that we do, especially tragedies involving children, or people dying young, will be taxed to the extreme.

When still active in obstetrics, I worried that I would have to attend deliveries in two hospitals at the same time.  In fact on more than one occasion I went from delivery room to delivery room in one hospital to the delivery room in the other hospital; my personal record for deliveries in one night stands at five.  I left that part of my practice and I hope I never best that record.

A part of emotional preparation for call involves finding the break point, a goal I set myself, a time to reach, and if I can just get that far I can handle the rest of the call.  On most weekend calls that hour comes at noon on Sunday.   Looking at tomorrow’s schedule, trying to figure out that point in the time line, I realized things didn’t look right.  In short order, I found I’d misread the call schedule and that my next night on call would be the weekend.

Better than a snow day during finals, better than finding a fifty dollar bill, that realization exceeded the rush of winning a raffle. 

I whistled and grinned and told jokes for the rest of the clinic session.

OK, I do those things anyway, but today with more intensity.

 

 

The difference between a medicine and a poison, the difference between the life of the party and a drunk

August 9, 2012

Tell me, what do you think,

About having the occasional drink?

If it’s one, sometimes two

It’s a great thing to do,

Any more and you’re needing a shrink.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

I took premedical classes as the University of Colorado at Denver.  My biology lab partner and I stayed friends.  In the fall of my first year of med school, she wrote me that she had multiple sclerosis (MS).  In 1975, very little could be done to change the course of the disease, which usually progressed relentlessly shutting down various parts of the nervous system.  Three years later, she mentioned going to AA, and I expressed my surprise.  When pressed, she said, “Well, you’ve got your high bottom drunks and your low bottom drunks.  And thank my Higher Power I’m a high bottom drunk.”

By that she meant she had hit bottom before a lot of things had gone bad in her life.  Later clinical experience showed me that MS and alcoholism frequently, though not always, go hand in hand.

The alcoholic who hits bottom early in the course of the disease does a lot better than the ones who hit bottom late. 

Not surprisingly, alcoholics get sick more often than non alcoholics; and smokers tend to drink and drinkers tend to smoke.  Thus I see the spectrum of alcoholism from those who learn early to those who learn too late, from those who function well despite their drinking to those who don’t, from those who drink daily to those who drink once or twice a year but go all out when they do.

I’ve watched alcoholics destroyed their families, finances, bodies, and careers without figuring things out.  On the other hand I have known alcoholic professionals who did something crazy on a dance floor, heard about it the next day, and never had another drop.  They never went to meetings, but a lot of them embraced their religion.

In between I can tell you stories of hundreds who quit just before their liver or their heart or their brain gave out for good, those folks who came back from the edge of the pit and lived to tell the tale though they lived the rest of their lives with significant disabilities.

Most people know about alcohol’s tendency to damage the liver, and we all know about liquor’s brain toxicity.   Yet most alcoholics who keep drinking and don’t die of trauma tend to die from heart attacks and strokes brought on by intemperance; booze raises blood pressure, brings hardening to the arteries, and directly weakens heart muscle.

But wait, you say, isn’t a glass of wine a day good for you?

Sure, just like labetalol 100 mg twice a day is good for some people, but if you save 3 months worth for the day of the Superbowl, it’ll kill you.  Thus a medication differs from a poison by nothing other than the dose.

And women who drink a glass of wine a day double their risk of breast cancer.

In my experience, a typical alcoholic is witty, fun to be around, unique, and intellectually stimulating when sober. And when drunk he or she is just another drunk.

Weekend rounds in vignettes

August 5, 2012

This morning I rounded on nine

Three of them now feeling fine

It’s only a slip

That can fracture a hip

An ankle, a neck, or a spine.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

I rounded on nine hospital patients this morning.  The oldest 86, the youngest 19, all of them had more than one diagnosis.  I can’t give identifying information about specific patients because of confidentiality, but drama and irony fill the stories of the people who fill the hospital beds.

Schizophrenia makes a person more susceptible to disease, and the disease process is worse for having schizophrenia on board.  Most schizophrenics smoke, and a frightening number acquire insulin dependent diabetes.  They face problems at the time of discharge, if they can’t take care of themselves and lack financial resources, though most have government-funded insurance.

Anyone unable to care for themselves, with no money or insurance, represents a problem for the hospital.  A lot of nursing homes would go bankrupt if they kept more than one non-paying patient, and some couldn’t afford even one.  Nonetheless, the attending physician has to round on those patients, and has to deal with Utilization Review, a committee that politely and professionally asks why the patient has to stay in the hospital at a frightful cost.

Everyone who smokes knows they shouldn’t, and most intend to quit, but I get a lot of business from people who don’t quit soon enough.  Contrary to popular belief, most smokers die of heart disease and emphysema rather than lung cancer. 

Some people arrive in this world with bad diseases that they didn’t ask for.  Some give up hope at a young age, and bring me a lot more business than those who decide the make the best of a bad situation and take care of themselves as best they can.

Mathematical ability dissolves in alcohol, nobody can count after they’ve had more than two.  Which leads people to think that alcoholics lie, when in truth they’re just lousy estimators.  Continued alcohol use with hepatitis C, viewed by many doctors as an active death wish, leads to cirrhosis and a horrid, stinking death, frequently accompanied by dementia.  The combination affects a disproportionate number of people too young for Medicare, and, again, discharge becomes problematic.

The elderly come to the end of their road with or without dementia; their mental status has little to do with how much their families love them.  Whether beloved or not, the drama of the hospital scene transcends culture and language.

Though most alcoholics smoke, not all smokers drink.  The two most addictive drugs in our culture usually go hand in hand, and the presence of other mental or physical disease brings layer on layer of irony and problems, some of which can’t be solved. 

Bones break, most fractures don’t require hospital care, but while a person heals from a fracture they tend to get illnesses requiring hospitalization, which complicates the fracture care while the fracture care complicates their other problems.

Continuing education

August 2, 2012

 

The midnight oil I’ll burn

The facts can make my mind churn

If I fail or pass

The test or the class

There’s always more I can learn

 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

The doctors in our clinic attend brand-new infants, and obstetricians frequently call us to be present at C-sections.  Today we did the Neonatal Resuscitation Program.

Enough of us in one place at one time justified importing the teacher with equipment and models.  In the interest of efficiency, the American Academy of Pediatrics has published a book and put the test online.  At least in theory, people read the materials, watch the DVD, and take the test at their pace and convenience. 

Two of our docs did the right thing and prepped for the course starting a month ago, then completed the exam in the week or so before the program.

The rest of us did not.  I read the first two chapters in a desultory fashion over the last month (5 twenty-four hour shifts in eight days, and the subsequent recovery put a dent in my study time), leaving 230 pages and 7 chapters till the last night.

In high school I developed the skills required to master a large amount of academic material in a short period of time, and retain the knowledge for decades.  Unfortunately, having that ability discourages me from working ahead.  I have stayed the king of the all-nighter ever since.

In my business I get a lot of night-time stress and job-related sleep deprivation, and as the years go by it takes me longer and longer to bounce back.

This morning I slept about an hour between study sessions, from 3:00AM to 4:00AM.  The experience hasn’t hit me nearly as hard as such experiences do when I’m on call.  I suspect the fact that I knew the phone wouldn’t wake me, so that I got an hour of quality sleep without vigilance interference, buffered the blow.

The instructor showed up late, and while we waited, and the doctors gathered in the conference room, we talked.

Of course we started with the call schedule and how we’re creeping to burnout.  But then we moved on to patients and attending physicians, and the knowledge started to flow. 

Colloquia and collegiality run together in medicine; in pre-med and medical school we used the buzzword peer mediated learning.  Our instructors wisely saw that we would need to learn for the rest of our careers and that other docs comprised a handy resource.  In short order I felt better about my procrastination and the amount of time I’d taken. 

The teacher arrived, showed us the equipment, had us demonstrate manual skills, then threw scenarios at us, describing newborns going bad.

We did well as a group and as individuals.  If one of us hung up on a decision point, the others helped out, and we all learned thereby.

When I started out my premedical studies, I looked ahead to eleven years of hard academics, and decided that if the end does not justify the means I had better embrace the learning process.  And that process never ends.  Every time I open a journal or listen to a disc or go to a meeting, every time I sit down to talk with my colleagues, I come away a better doctor.