Archive for May, 2013

Mothering, fathering, and dead baby monkeys

May 30, 2013

When it comes to a pigtail macaque

With a maternal quality lack

Life expectancy’s brief

If you bring it to grief

And don’t let the mother come back.

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.

During my premedical years I held a lot of jobs, some of them pretty weird.  One had to do with death, grief, and infant pigtail macaque monkeys.

At that time, an investigational neuropsychiatrist worked with pigtail macaque monkeys at the University.  On an irregular basis, he needed unskilled but intelligent labor to work all night.

The project involved taking an infant monkey, implanting three EEG (brain wave) leads, three EKG (heart monitor) leads, leads to measure time, temperature and muscle activity in the eyes and the back of the neck.  Those leads would feed into a radio transmitter the size of a matchbook, implanted in the monkey’s abdomen.  The signal would be picked up by a receiver in the next room, and the information recorded as a polygraph (much like a lie detector)on a piece of paper a quarter-mile long; remember these events took place in the age before digital recording.

The nature of paper records makes them vulnerable to failure of pen and paper, thus the project would pay a grunt like me to monitor the equipment.  I found it a good time to study.

The experiment aimed to find out exactly how an infant dies of grief; one can induce grief in an infant monkey by taking it away from its mother.

I do not know what journal published the results; I know that personal involvement in the study brings information that doesn’t make it into the books.  And I don’t mean the time that the alpha male monkey broke through the one-way glass and set out to terrorize the building.

Not all the experimental subjects died: hypothermia in the middle of the night provided the mechanism of death for those baby macaques; if you look in psychiatric journals from the early 70’s you can find that result.  But you won’t find quality of mothering as a predictor of death, and it’s very counter-intuitive.

One would think that a bad mother’s baby would be happy the source of irritation went away and would bounce right back, but the experiments showed just the opposite.  The infants of the good mothers survived, those from bad mothers didn’t.  The investigator hypothesized that the bad mothers took up all the offspring’s energy trying to get attention, and loss of focal point made for more intense grief.

I think that good mothering gave babies better emotional resilience.

My father-in-law died two weeks ago, age 90.  The death came suddenly but not unexpectedly.  Easy to love wholeheartedly but difficult to get close to, he and my mother-in-law gave their three children a firm emotional foundation.

 

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Job offers and Sisyphus

May 9, 2013

Call brings me no compensation

I struggle with documentation

I might sound like a boor

But our EMR’s poor

And a source of great irritation.

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’m starting to get wanderlust again.

Most days bring 6 to 10 job offers, some permanent, most locum tenens (temporary or substitute).  I look at locations and I fantasize.

Places interest me.  A spot in Wyoming evidently has terrible problems recruiting, I’ve received very good offers for the last 10 months.  Indian Health Service has a trouble filling positions as well.  Veterans’ Administration, Armed Forces posts, and Bureau of Prisons chronically seek physicians. 

The one that piqued my interest the most this week was Nome, Alaska, partly because I just finished Michener’s Alaska and partly because I worked in Barrow.  I wouldn’t really take the job because they want Family Practice with Obstetrics, and I swore off delivering babies on May 7, 2010.  Nor do I want to work more than 2 air hours from surgical backup.  Still it looked like a really, really interesting gig.

Ireland keeps sending me information about “hot jobs.” 

I have no interest in cities, not even exotic cities like Albuquerque or San Francisco, though I might consider something in the Denver area because of family and friends there.  For some reason Wisconsin has fallen completely off my radar screen.

I don’t much look for pay rates; still I’m impressed by some of the figures I see.  Bottom lines upwards of $300K come occasionally, but what really catches my attention are the offers of extra money for taking call. 

Bethany and I had such a great time in Alaska in the winter and New Zealand in the fall. 

While I can still remember the absolute euphoria of coming home and seeing familiar faces and sleeping in our own bed, I can feel myself starting to find fault with my current job.  I have begun to dwell on the call for which I receive no compensation and the hours of documentation I do outside of work hours.  The electronic medical record system (EMR), horribly inefficient to start with, irritates me more and more every day.

And if I miss too much sleep I find judgmentalism creeping into my thoughts.  Hospitalizing the same people for the same problems (which come down to bad lifestyle choices) makes me feel like Sisyphus. 

Yet I really enjoy my coworkers, the morale of the clinical staff runs consistently high, and I like doing hospital work.  A lot of docs don’t.  Thus electronic and regular mail recruiting touts “all outpatient” in capitals with several exclamation points at the top of the page.

The clear ability to walk away from a job gives me tremendous negotiating strength.

Unlike Sisyphus, who had been condemned to eternally roll a boulder up a hill, only to have it roll down just before it reached the top.

Sleepless doctors losing caring

May 7, 2013

We deal with death and with pain

The job brings a whole lot of strain

The hours on call

Are the worst of it all

When your sleep goes right down the drain

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.

Sunday afternoon in the doctors’ lounge the faces show the strain.  We have worked too many hours too intensely.  The energy and the intelligence helps but 48 hours into the weekend call the pulmonolgist, the nephrologist, the hospitalist, the cardiologist and the family practitioners have all done too many admits in the context of not enough restful sleep.

As a med student and a resident I had times on call when I made the mistake of letting myself go all the way to sleep, and then I aroused only with difficulty.  Now amusing stories at the time carried frightful embarrassment.  Most docs had similar experiences, and we learned to doze rather than sleep fully.  I’ve asked other physicians, and about 15% say they can sleep well if they’re on call.  I fall into the other group. 

The muscles in my upper back and the base of my neck grow tender knots and then cramp up. 

With the geographic layout of our town’s two hospitals, walking from car to patient to car, a round trip of hospital-patient-hospital-patient comes to a little over a mile, and with admissions piling up at the average rate of 4 to a shift, physical fatigue adds itself to the list of emotional and intellectual weariness.

Even the brilliant, overachieving docs from other countries who work insane hours without complaining (the way I did as a resident) look tired.  While no one wants to be seen as a whiner, we commiserate and we wonder why this weekend, of all weekends, should be so hard.

My near participation in the pity party ends when my beeper for the other hospital goes off.

I can tell from his use of profanity that the ER specialist has passed his emotional elastic limit.  All his rant about the alcoholic’s manipulative behavior rests solidly on truth, and I recognize in my heart my own impatience with the self-defeating behaviors that brought the person in.  But the doc on the other end of the line goes on for minutes, communicating little about the patient’s medical condition and much about his own anger. 

Across town the patient’s blood alcohol level runs 224.  From experience I know that the interview process will yield little useful information.  Drunk patients want to appear clever and they want to talk and they have problems focusing, but as a physician I just want to collect the information and go home.  I don’t try very hard when it comes to my 140 question Review of Systems, where I ask the patient about every symptom possible.  I break off questioning at the first sarcastic remark, and I don’t try to fight the scrunched-up eyelids to examine the pupils.  My dictation uses the sentence, “could not be obtained because of patient intoxication” a lot.

Overworked docs with inadequate sleep may or may not provide the same quality of care as normally, but they definitely lose out on caring.

Sick young men

May 5, 2013

 

In came the sickest of blokes,

He drinks, he gambles and smokes

Before he’s wise or he’s sage

He’s at such a young age

And I broke the bad news to his folks.

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.

The clinical theme of my weekend call has run into the realm of young men with very bad disease.

Any serious illness comes with a certain sense of irony and brings drama to the family context of the patient.  Advanced age lessens drama; a heart attack in an 85-year-old doesn’t carry the same emotional weight as a heart attack in a 35-year-old.

Most of these patients have problems with alcohol and tobacco, and their sum total of illnesses reflect more their life style choices than their heredity; some of the worst problems, though, showed up gratuitously, unannounced and unexpected.

So common do the three problems of diabetes, high blood pressure and high cholesterol run together that when I transfer information from one source to another the number 3 serves as my notehand for those three diagnoses.  That single digit showed up in more than 80% of the work-ups I have done so far this weekend.

But that trifecta in and of itself doesn’t lead a person to hospitalization, but the sequelae from narrowed arteries can bring on heart attacks, stroke, coma, and respiratory failure.

As the day waned and the sky darkened, I sat and talked with a justifiably worried family about a very sick young man.  The relatives didn’t hear the implication of the possibility of a fatal outcome until I stated it explicitly, and I had to endure looks that could kill messengers.

Any family conference involves a lot of questions.  Most interviews start with questions about the illness but progress more and more to issues with emotional content.  Those last parts tax my skills as an interviewee the most, but they bring me a sense of where the person fits in the web of their family; they take a lot out of me emotionally.

An hour later, In the ICU of the hospital on the other side of town, I interviewed and examined a young man who looked twenty years older than his real age.  The things the medical community had warned him about as a teenager had come to pass.  He didn’t wrestle with existential questions, nor did he want to change his lifestyle.  When I finished with the patient, I found no family to explain things to. 

A physically sicker patient in a sociologically healthier context brings a sense of tragedy more fulfilling than that of the ailing loner.   Contrast remains the essence of meaning.