Archive for November, 2012

Efficiency as the enemy of flexibility: a drawer’s maximum utility comes at 2/3rds full.

November 28, 2012

Time will flee by the slice

A slower pace would be nice.

All work and you’re dull,

If your day is too full

Efficiency comes at a price.

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 throes of student poverty kept me from owning a motor vehicle till I was 29, and I learned a lot about bicycles.  Efficiency rose with tire pressure as rolling resistance fell, but the efficiency came at a cost.  The extra hard tires did poorly on rough roads, skidded dangerously in the wet, could not be ridden at all on dirt, and punctured with the shortest of thorns.

My first vehicle, a Karmann Ghia, sported a Volkswagen engine, known for accessibility.  I soon found I could tune and tinker and get exceptional mileage, but I could only maintain 32 miles per gallon in ideal conditions.  Head winds or tire pressure loss from a drop in ambient temperature would shave 5 to 8 miles off of a gallon of gas; carrying a passenger made things worse.  And if the car sat for a week between trips, evaporation of gas from the tank dropped the road efficiency noticeably. 

Any system that gains efficiency loses flexibility; a drawer’s maximum utility comes at two-thirds full.

Our health care system stands as a paragon of inefficiency but it does well for flexibility.  Most years, our hospitals meet influenza’s challenge head on.  We have enough overbuilt infrastructure to handle a 30% rise in hospital cases.   

In the dark days when I worked 84 hours a week, I did so with tremendous efficiency.  I knew as soon as my foot hit the floor in the morning where my steps would take me till I dropped into bed that night.  Yet I paid a terrible emotional cost for the tiniest of delays, and I always ended up running behind before the last patient finished.

At that time I learned great efficiency in making rounds on hospital patients, but my system doesn’t tolerate glitches well. 

I need an early start.  On first arising, people don’t talk much, but by 10:00 AM the urge to speak has come to full flower.  It doesn’t spare doctors in general, nor nurses, nor this doctor in specific.

I used to joke about MYF, Morning Yack Factor, a hormone that drives people to verbosity.  Others have asserted it has more to do with caffeine finally reaching a threshold level.  Yet I don’t use the stuff and I still lapse into eloquent excess at midmorning.  I do my best to avoid physician conversations between 9:30 and lunch if I don’t have a morning running on leisure.

If our government in Washington doesn’t hold the world’s record for inefficiency, it should.  Note that we were able to wage not one but two wars without noticeably increasing the personnel in the capital. 

If the Affordable Health Care Act brings efficiency, our system will lose flexibility

Life comes down to a series of tradeoffs.

But realistically, I’ve never seen government regulation increase the efficiency of anything.

 

Morning rounds before Thanksgiving.

November 22, 2012

I started my work in the dark,

At the hospital next to the park.

Up and down floors

And in and out doors

The contrast and irony stark.

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 54 hours a week.

I enjoy starting early.  On Mondays and Wednesdays I do my group’s hospital rounds, and I like being in that first wave of doctors that hits the nursing floor before the chaos of shift change.

The more efficient I get, the more I enjoy inpatient work.  A doc can save a lot of time if he or she starts at the top and works down but today I started with the sickest patient admitted overnight, on the fourth floor, not the sixth.

I gained time because comatose patients don’t talk, and lost every minute trying unsuccessfully to access the outpatient record electronically.   Faced with an unconscious, non-English speaking patient, no available family members or other source of data, I did the best I could.  I left orders for social workers with interpreters to locate family and clarify the Do Not Resuscitate status.

Down the hall, the next patient, also requiring a history and physical, presented a dilemma: a narcotics addict with a legitimate, acutely painful physical problem.  I wrote orders for generous doses of narcotics in a patient-controlled anesthesia (PCA) pump.

I dealt with nurses panicking about a rumored bedbug found in the ER, pointing out that wearing infection control gowns , gloves, and caps wouldn’t do anything to prevent the spread of real bedbugs.

On the other side of the nurses’ station, I discharged a large patient with a 14 item problem list, who will need outpatient IVs for weeks.

I didn’t see the last patient on that floor, absent for treatments across town, but the ward clerk told me when to return.

Five minutes here and there add up, chasing patients wastes time, and I could feel efficiency fleeing in front of me.

I set off upstairs.

Some people don’t stop unhealthy behaviors soon enough, and physicians like me sometimes have to sit down with families and talk about time expectations measured in a week or two.  We discuss ventilators, resuscitation, and the vital business of saying what you have to say to the people in your life NOW because you might not be around to say it on Monday.  The patient said, “I’ve had a good life.  I’m not afraid to die.”  I talked with the consulting subspecialist who confirmed a very poor life expectancy, and gave me a decades-old formula . My calculator came to 63 when anything over 32 means less than a dozen days.

Three doors down I discharged another patient, mixing Spanish and English, and getting pieces of a fascinating life story, an odyssey crossing and re-crossing international boundaries.

On the other side of the building, inside the locked doors of the psychiatric unit, I discharged a person showing remarkable insight and taking complete personal responsibility, after a discussion of the fine points of a borderline vitamin B12 levels.

Two stories down, I discharged another from the orthopedic floor, who also had vitamin B12 problems and severe vitamin D deficiency.  Two doors up the hallway, the patient showed progress but not enough to leave.

Up the stairs again on the fourth floor, five minutes fled while the patient arrived from across town.  Optimism suffused the visit with four family members and a patient with a grim diagnosis and a good attitude.

Two floors down another admission involved a newborn, with the shortest of histories and the most efficient of complete physicals.  I spent more time talking with the parents than actually examining the patient.

Thus in the course of my hospital morning, I took care of 8 patients including 3 admissions and 3 discharges (with discharge summaries).  Diagnoses included metastatic cancer, end-stage liver disease, hip fracture, kidney failure, dementia, end-stage pulmonary disease, bipolar, alcoholism, depression, diastolic heart failure, sepsis, epididymitis, diabetes, hypertension, coronary artery disease, stroke, narcotics addiction, sepsis, urinary tract infection, and completely normal.  Life expectancy ranged from less than a week to 86 years.  Family involvement went from none to surrounded by warmth, and emotional impact of disease ran the spectrum from despairing acceptance to outright joy.

Contrast is the essence of meaning.  I finished before noon.  I lunched with my colleagues in the doctors’ lounge, discussing hospitalized patients with consultants. The erudition beat the chili.

Taking the pulse to get through the denial

November 19, 2012

How do we know what we know,

In a patient denying it’s so?

A two-week-old start

For a pain from the heart

Was part of a tale of woe.

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 54 hours a week.

A doctor has to listen as carefully to what the patient says as to what the patient doesn’t say.  I don’t think any of the standardized tests given to doctors measure the ability of a physician to detect deception and denial in the history given, nor how to sneak through the web of drama and irony to get through to the truth.

I nodded while I listened to a patient talking about symptoms identical to the last three visits.  Taking full responsibility for the ruination of a perfectly good set of lungs, the patient seemed to me a little too cheerful.  In the middle of a digression I reached out my hand to the patient’s, and feeling the pulse, waited till the smile faded a little and I could speak without interrupting. 

“I think you had crushing chest pain for hours, going up into both sides of your jaw, with sweating and nausea and shortness of breath even worse than usual, about two weeks ago, and it went away and ever since then you’ve felt just terrible.”

The gaze dropped and the sigh came through over the gentle hiss of the oxygen as the smile faded. “That’s about the size of it.”  I kept my index and middle fingers on the pulse and I waited.  “You don’t think it was a heart attack, do you?”

“I do,” I said. 

“Well, I guess I thought so to, or else I wouldn’t have made the appointment.  I just didn’t want my daughter to know, she’d have made me go to the hospital.”  We looked at each other and burst into laughter.  “That sounded pretty stupid,” the patient said.

“There’s a difference between fear of hospitals and stupidity,” I said.  “We need an electrocardiogram and a chest x-ray.”

After the lab studies confirmed what I already knew, I started into the part of the interview known as the Review of Systems.  “Any depression?” I asked.

A shake of the head, followed by, “No, no, not at all.  Not anything worse than usual.”  I reached my hand out again and the patient’s forced smile fled.  “Yeah, I guess I’ve been pretty depressed ever since.”  I nodded and we laughed again and then we laughed because we were laughing about depression.

The patient gave me permission to write a good deal more information than I have, about a visit stretching over an hour and a half, and touching on issues of intergenerational conflict, ripples of familial dysfunction getting worse and getting better in children and grandchildren and great-grandchildren, nosology, intellectual honesty, freedom of choice, and game theory. 

I ended up giving bad news and reassuring at the same time.  I arranged for proper follow-up and explained new medications. 

Of course when that patient left I went on to the next one and apologized for running late.

 

Reversal of knowledge flow: heart attacks, beta blockers, migraines, sleep, jet lag, and premature ejaculation

November 15, 2012

A piece of wisdom, please heed.

If you want to know more, you can read.

But don’t think to balk

At the casual talk

Between docs.  It’s something we need.

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 54 hours a week.

Quite some time ago I attended a series of patients with porphyria, a blood disease so rare that most doctors will never see a case.  When the dust settled I had successfully proven the diagnosis three dozen times.  The story of the research I never published and why I would even think to look in a particular bunch of selected patients would take pages and would only interest a small handful of people who probably would never think to look at my blog. 

I learned that if a doctor reads for four hours about a disease, he or she will know more than half of the doctors.  Eight hours of study will bring one to a state of knowledge greater than 80%, and sixteen hours will put a physician in the bottom half of the top ten percent.  But to get to the top of the top requires years of study and clinical experience.

No doctor can know everything about everything, though one of my colleagues comes close (he has good social skills, too, and if we could clone him I’d be out of a job).  Average front line docs have, on average, about the same level of knowledge.  I really, really like hospital work because it makes me talk to doctors who know more than I do.

Most of the specialists and subspecialists I deal with approach the knowledge gap gently, and every conversation brings me to a richer state of learning.  Once in a while, I get to push the knowledge flow the other way.

An excellent conversation over mediocre hospital food with a cardiologist started with discussion of the fine points of managing heart attacks, and brought us to a discussion of beta blockers, a class of blood pressure drugs that interfere with some of the actions of adrenaline.  Labetalol rates favorite status among some of the docs, he said.  I pointed out that it cost more than any other generic in the class; carvedilol, the most recently generic of the group, costs the least.  I looked at the priceless expression on his face and explained that I’d just talked with one of the Community Health Center pharmacists.

Then we talked about propranolol, the oldest beta blocker of them all.  The cardiologist mentioned that men won’t take it because of sexual dysfunction, I talked about how I prescribe very low doses to treat premature ejaculation. 

While the cardiologist listened, I held forth about propranolol’s uses having nothing to do with its original indication, hypertension.  His interested escalated when I got to migraines, which led me to sleep and thence to jet lag.

No reason, I asserted, to have jet lag in the 21st century.  A simple sequence of five drugs would multiply the effective days of vacation.

In the course of twenty minutes, I learned more cardiology, he learned a good deal about sleep management, and we both walked away better doctors.

 

Food uncertainty: salmon and heart attack

November 14, 2012

Uncertainty comes with the call

If you’re hungry you might hit the wall

But a cardiac doc

Gave quite a talk

Then time slowed down to a crawl.

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 54 hours a week.

As soon as I graduated med school I discovered that doctors never go hungry.   The doctors’ lounge in the hospital has pastries, fruit, and coffee in the morning and a lunch at noon.

Pharmaceutical manufacturers’ representatives, the drug detail force, line up to bring lunch and breakfast to outpatient clinics, in return asking for time to talk to the doctor.

As soon as I came to private practice, the dinner invitations started to roll in.  In 1987, the format included fine dining, a lecture, and a $100 check.  As regulations tightened, the out-and-out bribes stopped, replaced by “medically relevant” gifts; really good stuff useful for physical examination, like headlamps and otoscopes. 

Those gifts have gone, but the great meals continue in the century when I’m looking for opportunities to eat less and eat earlier.  I usually turn down the invites, especially if the lecturer comes from out-of-town.  But yesterday the chance to listen to a local cardiologist whom I trust and respect accompanied the chance to eat at one of Sioux City’s premier restaurants.  With call scheduled that night, I gave a tentative yes.

Clinic finished early with most of my documentation done.  I arrived before the appetizers. 

I enjoyed the lecture, I came to a better understanding of a beta blocker than few of my patients will be able to afford before it goes generic. 

But I paid the price of tension; call begets uncertainty and no one does their best work when hungry.  Eight PM came and went and the entrees had not arrived and my beeper went off.  The patient in the ER had classic findings of heart attack.  

A clinical summons always includes a time frame.  Flexibility ranges from drop everything to OK to wait till morning, depending on circumstances.  In this case the ER doctor had done all the right initial things, giving me a twenty-minute window.

I waited and the tension mounted.  Three minutes before I would have walked out without eating, my Scottish salmon with lotus root chip and black risotto arrived. 

I suppose it might have tasted good if I hadn’t bolted it, but bolt it I did and left, remembering how luxuriously wonderful cheese and crackers had tasted eaten at leisure on our Alaska road trip.

When I walked into the hospital I had the good sense to call ER first to find out the patient’s location.  After much dialogue I got a room number and I called the nurses’ station.  No such patient here now, they said.  I called back to the ER: nope, not here either; maybe X-ray; wait, please hold.  After a lot of hold, they told me the patient had just come back.  I went directly to ER.

Of course, I missed the patient who had been sent to an inpatient bed.  The nurses laughed, I didn’t.  When I finally got to the patient’s bedside, I had expended enough pursuit time that I could have eaten leisurely.

I had no way of knowing that beforehand.

Six hours of multiple choice questions at the rate one per minute

November 8, 2012

You can’t say we were having a blast

And six hours sure didn’t go fast

It was multiple choice,

Don’t mourn or rejoice,

I certainly hope that I passed.

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 54 hours a week.

Today I did six hours of multiple choice questions at the approximate rate of one per minute.  I did it so I can say that I am a Board Certified Family Practitioner.

Board Certification carries status, and status means money, employability and flexibility in the medical profession.  Each specialty has a Board that puts together an examination and sets standards. The American Board of Family Medicine led the way for regular recertification; when I first certified the Internal Medicine ticket remained valid lifelong. 

The generation of doctors who stopped their testing when they finished residency have started to retire; most doctors who call themselves Board Certified have to endure a torture every few years.

I logged more than 300 hours of Continuing Medical Education in the last ten months, and, in fact, I’ve been using some of the pearls I picked up.

Consider the dilemma of the doctor who doesn’t know if the patient has real seizures or pseudoseizures.  During residency I met a patient who knew a good deal more neurology than I did, and who could fake a seizure that would fool the best in the business (and, regretfully, the expertise brought about the loss of an arm).  Two weeks ago I learned a simple blood test, prolactin, if drawn within three minutes of the event can make the distinction with 95% certainty.

I took care of a hospital patient this last week where that single datum made all the difference to getting the proper care.

So studying for the test has brought me new, useful knowledge, but I doubt that the test itself measures the quality of a physician.  The immunization schedule, for example, came up three times.  I purposely refuse to memorize the sequence of shots because the recommendations keep changing.  If I need to know the dose of a drug, I consult my smart phone’s app, Epocrates. 

Too many questions came down to “Guess what I’m thinking.”

I had to bring my literal passport AND driver’s license to get into the test; I emptied my pockets and had to pass the metal detector wand (which failed to pick up my 1 ounce Navajo silver belt buckle).  After the first two hours I took an optional five-minute break, then worked on till noon and went out to hot lunch at the supermarket (very good Chinese).

By the time the last 80 minute session started my eyes had lost their focus and I had to fight to continue to care.  When I walked out of Western Iowa Technical Community College’s Testing Center I concluded that the test, more about test taking than about the material, was for the sake of testing.

I won’t get my score till December.  I hope I passed.  I don’t want to take that thing again.

Cramming II

November 5, 2012

This business of prepping for test

Is leaving me feeling stressed.

With style and flair,

I still love patient care,

While it’s cutting into my rest.

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 54 hours a week.

I have given entirely too much power to the recertification exam I have coming up 60 hours.  Studying for an important test rates as a good idea, but I have past the point of diminishing returns.  The end result cannot hope to match the excess of energy I have invested in it.  Sure signs of overload start with sleep disruption: I fail to rest not because I’m worried but because my brain’s acquire-new-information circuits have taken over and don’t want to shut down.

Another sign comes in the form of loss of skin turgor: if you pinch the back of my wrist the skin tents up as it would with dehydration.  I noticed that finding while in private practice, and regarded its reversal, when I went walkabout, with elation.

I have registered more than 300 hours of Continuing Medical Education so far this year, and while I really, really like learning I feel like I’ve lost perspective on the process.

Yet the stress of exam prep gives a poignant joy to everyday patient care; the written material contrasts with the richness of interacting with flesh and blood.  I do a lot of pediatric well exams, and I always check the patients’ feet.  I would rather deal with the olfactory sledge-hammer of adolescent foot odor than pulseless test questions.

In the course of my exam prep I learned the recommendations against certain aspects of routine screening.  For example, I’ll no longer recommend breast self-examination, nor prostate cancer screening.  But, despite what I’ve been told, I’ll still check for scoliosis in growing children.  The recommendation against the spinal exam comes from the rareness of the condition, and the doubtful value of treatments.  My reasoning goes something like this:  why not run a low hazard, low-cost test that has the chance of uncovering other serious problems like physical abuse?

I attended a WWII veteran today and treated myself to an interview about his service.  For those golden minutes I wallowed in the reasons I love my profession; the patient enjoyed the attention and I listened, rapt.  By the end of the visit the patient chuckled as much as he spoke.

One of my many patients still smoking despite very bad lungs wheezed through the visit.  As always, I advised tobacco cessation, and for a minute tension hung in the air until I made a wisecrack and we both broke into laughter.  I finished the visit, as usual, with a joke, which provoked more laughter and prompted the patient to say, “I’m glad I came into to see you today, doc, you made my day.”

“You made mine,” I said, and meant it.

 

Erode away your problems, ten minutes daily

November 4, 2012

If you can invest minutes ten

Every day, not now and again,

You’ll accomplish great things,

You’ll play and you sing,

And they’ll say, “You find time?  Tell me when!”

 

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 54 hours a week.

Erosion, the powerful force of geology, accomplishes more than cataclysms.

Sometimes I talk to young mothers overwhelmed by the mess in their house.  The child, they complain, has strewn everything possible all over the floor, and they don’t know what to do.

I explain that because children dwell on the floor and because they inherently generate chaos, the situation falls squarely into the normal category, and that trying to change the base cause of the mess ranks in futility with trying to stop the tides.

Maintaining steady erosion, I say, has a better chance of accomplishing the task at hand than trying to clear everything up at once.  Every time you pass a haven of disorder, put one thing back in its place.  If you have enough energy to sigh at the mess, you have enough energy to improve it a little.

Bethany and I started decreasing the number of our possessions 6 years ago.  We keep at it steadily, and every year we have less clutter.

One hour a day, 5 days a week, for eight weeks, separates you from the 300-word vocabulary that constitutes the basics of another language.  At the end of the first term you can make your needs known, and understand rudimentary concepts.  You won’t have fluency but you’ll have the foundation to build fluency.

In the last two years I have found practicing the saxophone 10 minutes a day more feasible and more pleasurable than the hour a day I use to aspire to. 

One can find ten minutes in a schedule easier than an hour, and ten minutes regularly brings more learning and finesse than an hour that doesn’t happen all that often.

Any activity we enjoy for ten minutes tends to extend as time goes on.  If I can get my diabetic patients into the habit of walking 10 minutes three times a week in September, by the time March rolls around I can coax them into 15 minutes at a time, and in a year or two I’ve gotten them up to 30 minutes six times a week.

When I set out to practice my saxophone for an hour, I often shorted my time.  Now that I only aim for 10 minutes, I get more out of my playing, I make more time to practice, and when I cheat, I go long, not short.