Archive for December, 2013

Jousting with idiots, wrestling with bureaucrats

December 31, 2013

For medical care you must wait

And drive clear cross the state

My patience it wears,

That Iowa cares

Is a program I just love to hate.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center, which dropped from 54 hours a week to 40 on December 1.

At some time in the past, Iowa, to deal with the problem of delivering medical care to the indigent, instituted the Iowa Cares program.  Start with a simple idea: any Iowa resident presenting to the medical center/school in Iowa City will get the best of medical care regardless of ability to pay.   Then offer primary care entities $20 for all the care delivered at any one visit, including lab and x-ray. 

A few people smart enough to make it through med school but dumb enough to take that contract signed on.  Thus people of little means ended up driving up to 2 hours for “free” medical care.

If the person needed inpatient care, the local hospital would pressure them to accept transfer to Iowa City.  Specialty care necessitated a hefty wait, and a drive across the state.

Those patients who went onto the Iowa Cares program had little in the way of assets.  Many lacked coping skills, emotional resilience, patience, forward-planning skills, impulse control, and memory.   They drove older, fuel-inefficient vehicles.  Some ran into cancelled appointments after an all-day trip.  Many had to give up Medicaid coverage to get Iowa Cares. 

Broadlawns, in Des Moines, picked up the contract for a lot of the specialty and inpatient care, which brought the drive from 8 hours to 4.  But four tanks of gas (never mind snacks on the way) and a motel room can easily run into the triple digits, which puts the lie to the concept of “free” medical care. 

This summer, with the anticipated flowering of Obamacare, the University of Iowa announced that the Iowa Cares program would close on midnight of December 31. 

Yesterday, with less than 36 hours left in the program, a patient came in for a first Iowa Cares visit with me, at 2:15PM.  In less than 5 minutes, I knew the patient needed surgery; a 10% weight loss in 21st Century Iowa, never normal, ranked as the least of the physical findings.  No, I told the patient, the clinic 75 minutes’ drive from here hadn’t sent the information.  I called them.  The nice lady at the other end promised I could have the documents by the end of the day.  Not good enough, I said politely, I needed them within an hour, and quickly faxed a Release of Information.

Outside, snow started.

An hour later, I had the information in hand, and I had our Iowa Cares specialist start the ball rolling. We needed a full-time tough, savvy, smart person just to deal with the program.  She keeps detailed notes, and pointed to the entry where she told the original primary doc to arrange surgery ASAP; the names and the date 2 weeks prior jumped off the page at me.  I knew I’d have to tap dance and sprint to get things going before the end of the business day.

I called the doc at Broadlawns ER.  He couldn’t accept the referral, he said, I’d have to talk to the surgical subspecialist on call, but if I suspected cancer, the patient would have to go to Iowa City. 

I could marginally justify sending a patient out on marginal roads for 4 hours but not for 8.  Could I just send her to our ER in Sioux City?

No, I had to talk to the Broadlawns doc.

After wending my way through phone trees and blockers, I left my cell phone number with someone who accepted the transfer without having the authority.

The call came at 4:45.

Medical school taught me a lot of things, but it didn’t teach me jousting with idiots.  I had to learn that on my own.

I tried to break into a tirade of arrogance twice and the third time I said, “Look, just stop interrupting me for one minute, OK?  If you refuse the transfer, it works for me, I would just as soon send her up to my local ER.”

No, he wasn’t refusing the transfer.  But it took him five minutes of belittling and insulting me to accept it.

I’ve run into such resistance in the past, always in the context of doctors horribly overworked in a dysfunctional system.  Though those individuals irritate me to no end, I feel for them.

The patient left into a thickening snowstorm.  I received word today the hospital care had started and the condition had stabilized. 

But if someone postpones surgery past midnight, when the Iowa Cares program stops, I don’t know what the patient will do.

 

Call without flak jacket

December 22, 2013

For call, the way to prepare

Is to grit your teeth if you dare.

But this busy season

The load’s come within reason

And doesn’t hold much of a scare.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a position with a Community Health Center which dropped from 54 hours a week to part-time on December 1.  I’ve also done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and a trip to Mexico for our daughter’s wedding.

It’s Sunday evening and I have weekend call but the meaning of that phrase has changed substantially. Joyously and radically.

Our practice gave our adult inpatient work to both hospitalist groups.  But internists only staff those, and neither will care for patients under the age of 18.  Thus we still attend pediatric and newborn patients.

I rounded on and discharged a young teenager at one hospital and two newborns at the other yesterday.  Today I sent those two babies home and admitted another newborn.

During medical school, standard practice demanded keeping newborns in the hospital for 5 days following normal delivery and a week following Caesarean section; by the end of residency the stays had dropped to 3 and  5 days, respectively.  Down to 2 and 3 days currently, we don’t see nearly as many septic babies as we used to when we kept the children longer in the germ-laden hospital.

When I go to the hospital and I print out the census for my group, I see names of patients admitted from our practice but on whom I don’t have to round.  One hospital had 5 names and the other had 4 yesterday and today the total came to 12, when a month ago our minimum total came to 20 and frequently ran over 30.

I have to ask myself if our respectful, expert care had anything to do with the fact that he patients kept getting so sick.  Certainly I find it believable that the drinkers would fail to learn if our well-oiled alcohol withdrawal machinery did such a great job of keeping them comfortable while they sobered up.  After all, people will jump more if you keep setting up the safety net.

But I also have to ask if our sicker patients have switched to doctors offering better continuity of care.

I slept well last night; I received no calls in the critical hours between midnight and 6:00AM.  I still got up early, had a good breakfast and went to work.  But afterwards I could go to the gym, go to brunch, take a nap, do some reading, and take in a movie.

And I could do it all without vigilance ruining the experience.

 

We used to talk about the emotional preparation for taking weekend call as “getting your flak jacket on.”  That 72 hours could be physically and emotionally exhausting, but we figured if we could make it to Sunday at noon we could handle any evil that would last less than 18 hours.I look forward to getting back to the office tomorrow.

I’m really enjoying my job now; easier without a flak jacket.

Hazardous communications from OSHA

December 6, 2013

Just me and one other bloke

Were the ones who caught onto the joke

I’m not quite the lone ranger

Who thinks that the danger

Of boredom might be a stroke

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, had adventures working in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and a trip to Mexico for our daughter’s wedding.

Our clinic runs an All Staff meeting the first Thursday of every month, which included two segments of required training, one on harassment and one mandated by OSHA for health care facilities.

I have seen the OSHA video, copyright 2007, twice before.  Its cognitive content takes less than one-third of its running time.  As the poorly written dialogue progresses, people in the room lose interest.  Soon the murmur of polite whispers permeates the room.  Attention drifts.  I daydream but I don’t get out my smart phone to check my email.  One of the docs at the next table starts working on clinical documentation, and I don’t blame her.

For unknown reasons I look up at the screen at the moment it displays two words:  HAZARDOUS COMMUNICATIONS.

I hadn’t thought about it, but I suppose communications could be hazardous, especially if incomplete, ill-intentioned, or dysfunctional.  I don’t remember anything about communications from previous viewings.  But if that header has accuracy, why would the artwork include pictures of chemistry glassware?  I turn to the nurse next to me and point out the words on the screen.  She hadn’t been watching, either, but she smiles.  I look around to find no one looking at the program.

I decide that hazardous communications include those from OSHA and other regulatory bodies who think that making us watch boring, inaccurate and out of date videos will result in something positive.

The video continues on with five minutes devoted to weak humor involving picric acid.  A few people glance at the screen, but most are chatting just above a whisper and filling out the test questions.

Of the roughly 150 people in the room, the vast majority have seen the program more than three times.

The next speaker on the agenda points out the mistake.

What a shame that only two of us caught the joke.

Last bad night on call

December 5, 2013

The night is now over and passed,

It left me a little bit trashed

Yet I have had worst

And it wasn’t the first

But of bad call, I hope it’s the last.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and a trip to Mexico for our daughter’s wedding.

I start early because I can’t sleep past 5:30AM and I get to the office at 6:40 and start plowing through documentation from the day before; every 4 hours of outpatient contact generates an hour of documentation.  I walk into the exam room for my first patient promptly and on time at 8:00, and I finished the morning, strangely, at 11:45, leaving me free to sit down and work on the morning’s documentation.  I even get downstairs to the lunch room, to heat up my elk meat and rice in the bank of microwave ovens.  But more work piles up on my computer desktop while I eat, and drains time and energy till my nurse readies the first patient at 1:15.

At 4;45PM a PA brings me upstairs for a patient needing admission.  At 4:55 I start on the last two outpatients, apologizing for my tardiness.

The upcoming holiday mandates I complete the afternoon documentation before leaving at 6:15 PM.  I get home to microwave two tamales (homemade by a patient). I eat 1 3/4 and get  a call from Labor and Delivery: “We’re going to C-section.”

At L and D at 6:55 I find out that the procedure needing my attention comes next; nurses tell me how much they appreciate it that I just come when called without whining first.

I fill the time with a surprise encounter with an endocrinologist, whom I hadn’t seen or talked to for months, reviewing electronic documents, and chatting with residents and staffers about the low quality of Electronic Medical Record (EMR) systems.  I bring up MedTech32, New Zealand’s national EMR, simple, intuitive, robust, reliable, producing useful documents and organizing data well but useless in a world of defensive medicine.

Down the hall another baby enters the world and our nursery service.

8:00 PM I start to scrub and my beeper and phone go into meltdown mode.  I have the nurse call the operator to hold calls.

The section goes well, the red-haired boy cries, pinks up, then starts to struggle for air.  Drama enters my world while the beeper and cell phone restart insistent chiming.

The baby stabilizes in the recovery room with some oxygen, his nose stops flaring with every breath and he pinks up again.

At 8:30 I get to the telephone and start to make calls; two patients await me at the Emergency Room.  The medical nursing floor has a number of questions and I suppress the urge to scream while the jolly nurse kids around before getting to the point.

With three places needing me simultaneously, I change out of scrubs and make more calls.

The beeper sounds again for the same ER across town, the call tells me that one of those patients in fact belongs to another clinic, and my tension plummets by a third.

At 9:30 the ER patient comes with a family context, a bad infection, and a full back story.  But she doesn’t want to talk and extracting history takes little time, the physical less, and the dictation but 6 minutes.  Putting the orders into the computer lasts as long as the previous  steps put together.  I get home at 1030 and into bed at 1115.

Five minutes before midnight the phone wakes me out of a sound sleep, and I head back to the ER that I just left.

Cigarettes stole the breath of a young person who continues to smoke and doesn’t want to quit.  Carbon dioxide has built up while oxygen plummets and the short-term starts to look as bleak as the longterm..

Despite the gasping, the patient has a tale to tell. I listen and take notes, and eventually I ask my series of 84 yes and no questions.  The BIPAP mask cuts the physical short, I can’t remove the machinery without endangering the patients life.  Again, I spend more time at the computer than I did with the patient, but when done I go back into the 8 bed ward and exchange pleasantries with a PA I knew from my Indian Health Service days; she came with a relative and a story full of drama and irony.

I arrive home at 1:10AM.  Sleep comes with difficulty, and arrives fragmented.  No calls comes before I give up on slumber at 5:00AM.

I had a bad night on call, though I have had worse.  I will have more call nights, with babies and children, but none of them should be bad.