Archive for January, 2014

Exercising my buprenorphine waiver for the first times

January 29, 2014

With my patients I can make a pact

Per the modified Harrison Act

Buprenorphine,

A blocker of morphine

Can help, and that is a fact.

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; I’m now down to 40 hours a week.

In 1914, the Harrison Act mandated that physicians could not prescribe narcotics to treat narcotic addiction, which, at the time, seemed a pretty good idea.  Using morphine to get someone off heroin, or vice versa, didn’t make much sense. Yet 3000 doctors went to jail for defying the Act.

Time marched on, and scientists discovered compounds that could counteract morphine and its cousins, giving rise to a new class of chemicals, narcotic antagonists.  The novel drug naloxone (trade name, Narcan) came during my time in med school, and quickly became a staple in ERs all over the country.  If someone came in OD’d on heroin, you could just inject a vial or two and save a life.

Further chemical sophistication led to drugs with mixed effects; in some ways like a narcotic blocker, and in some ways like a narcotic.  In residency, when confronted with a drug-seeking patient, I learned to offer one of these narcotic agonist-antagonists, warn the patient of withdrawal if they were addicts, and watch them storm out of the ER.

As time went on, methadone showed its utility to block narcotic’s euphoria or high and squelch craving for narcotics.  Because of the 1914 law a doc could use methadone to treat pain, but could only use it to treat addiction in a licensed methadone treatment center.

Buprenorphine, a compound available since 1980, eventually established itself as a useful agent in treating addiction.  Again any doctor with a DEA number could use it for pain, but only those with a special waiver could use it to treat addiction.  But that treatment could be based in a physician’s office.

In our quadrant of the state, only 3 doctors have that waiver, though it takes a mere 9 hours of education to qualify.  I got mine over the summer so I could fill in for one of my partners.  In the time since the only methadone program in a hundred mile radius shut down.  And for months, the only patients who showed interest would not have fit the entrance criteria.

In the last two weeks, three patients have requested entrance into the program.  I confer with my more experienced partner on each one.  He tells me his buprenorphine practice brings him tremendous satisfaction.

I have cared for one of those three patients since I arrived at my current position, and writing that first prescription came as a relief.

Confidentiality limits what I can say about the patients, but it doesn’t limit what I say about myself.  I have lots of first-hand experience with chronic pain, and today ranked as one of the worst since the summer.  I try to walk normally, and I try not to grunt or grimace when I sit down or stand up.  I focus on the patient, but I also tell my story.  Those who want to score drugs for remarketing show themselves with stridency, those who listen usually end up demonstrating a real desire to get on with their lives.

Once, a patient revealed that the pain had completely gone, obviating my tale.  That happened only once, and the story brought light to my day.

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Making my day

January 19, 2014

Two patients sure made my day

With rewards much better than pay

It brought me great mirth

For I had attended the birth

And had followed them up all the way.

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. 

On a windy day last week I took care of a patient I’ve known for more years than she has breathed air.   I promised not to write any other details about her case; she gave me permission to mention her gender and age.

When I started in at The Practice Formerly Known As Mine, I still delivered babies.  But I recognized back then that male Family Practitioners in obstetrics qualified as obsolete.  At a meeting in 1987, I said to my partners, “We’re dinosaurs.  Does anyone here really think we’ll still be doing OB in 10 years?”

We all shook our heads.  But 1997 came and went and I still did OB, and one member of that group continues to this day.

I stopped delivering babies on my 60th birthday in 2010, but only after I had done a couple of second generation deliveries.  Along the way I followed people and families, from making the diagnosis of pregnancy through the prenatal care to the delivery, then the well child checks, the sports physicals, and the college physicals.  And then I saw those people make their new families.

I had seen that person grow past infancy to childhood to adolescence, past callow youth to young adulthood.  And then I attended to her needs again, now 23 and a responsible adult accompanied by her child.

Those moments bring rewards that cannot be measured and often lack description.

Without a better term, I’ll use the words depth of joy to describe my feelings during the visit.  It suffused the minutes I spent with her, and at the end, I told how good she looked.

My day continued, the glow from the Family Practitioner’s moment stayed with me, while outside the snow fell and dusted the streets, then the sun melted the snow.  I took care of baby boomers paying the piper, well two-year-olds, refugees struggling with English and Hispanics becoming Americans.

After 4:00 I took care of another patient whom I had delivered, decades ago, and followed through well child checks.  Just to tell me things had gotten better and the medication wasn’t needed any more.  Having figured out the stressor and gotten rid of the toxic person, the migraines had disappeared.

A phone call could have accomplished the same purpose, but it wouldn’t have made my day.

A part-timer goes part-time

January 9, 2014

We were just about to our knees

“Part-time” was only a tease

We’re doing outpatient care

And we’ve time to spare

And full-time seems like a breeze

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.   

On December 1, our clinic relinquished adult inpatients at both hospitals to the two hospitalist services.  We continue to take care of hospitalized children and newborns.

When I first signed on, my contract specified I would see hospital patients in the mornings and take care of outpatients in the afternoon.  Within six months our hospital practice had grown past the point where one doc could take care of the whole census, and we hired a fulltime hospitalist.

Rarely do situations stay stable, and our inpatient load expanded to the point that our full-time hospitalist needed a “hospital helper,” to see patients under the age of 18 along with one hospital.  The hospital helper would finish morning rounds, and do afternoon clinic.

We handled the daytime work without problem.  I enjoyed the physical, mental, social, intellectual, and spiritual challenge of hospital work.  The nighttime call burden became unsustainable.  Most evenings after clinic, “call” meant admitting patients at both hospitals till 11:00PM, and a minimum of 6 phone calls between midnight and 7:00 AM.  The vast majority of the phone communications involved making life-and-death decisions, and each one demanded awakening fully.  As time progressed, our patient numbers increased, and the patients we cared for grew sicker.  And my part-time position came to eat 54 hours a week, not counting time required to recover the day after call.

As our staffers drifted towards burnout, our devotion and caring for each other never faltered.  Each of us tried to make adjustments to cope with the unreasonable.  One used vacation days to not work Tuesdays, one went to part-time.  I took a cut in pay so I wouldn’t see patients the afternoon after call.  And I formulated an exit strategy.

I had tap danced on the brink of burnout before, I could sense the symptoms coming back, and I didn’t like it. The more my fatigue, the less my empathy.  One evening I recounted a conversation with a particularly difficult patient to my wife.  “You’re angry with him,” she said, “He deserves a different doctor,” and I couldn’t deny the truth.

It took a new CEO with incredible negotiating skills to recognize the problem, devise a solution, and implement it.

You can see the relief in the faces of the physicians now.  With clearer complexions reflecting better sleep, we tend to chuckle, giggle and laugh when we talk.  Most night call involves more mistake beeps than real ones.

One can easily see the toll the vigilance takes during call hours; the doc stays on edge waiting for the next interruption.  We did not anticipate the relief that would come from general stress lowering, but that relief has come to us, very real and very strong.

Our patients have lost little continuity of care, the theoretic advantage of a practice holding on to inpatient duties, because the burden demanded rotation.

For the first time since I finished undergrad, my work week comes close to 40 hours and most weeks finish on Wednesday.   I have time for both recreational reading and for writing.

I’m back from the brink of burnout.  Again.