Posts Tagged ‘bipolar’

End of a Canadian month

May 7, 2018

I have to leave by the first day of May

At least that’s what the border guards say

So my bridges don’t burn

I plan to return

And next time for a 90-day stay

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

I wrapped up April’s assignment today with a full clinic. I attended 18 patients.

I have written before about propranolol, a remarkable drug whose new uses have vastly eclipsed the original indication, high blood pressure. I prescribe it for stage fright, social anxiety, ADHD, buck fever, overactive blushing, and migraine.  Today two of my patients received prescriptions for propranolol; one has taken it for years for stuttering, and it works well (I received permission to write a good deal more than I have).

Seven patients’ medical problems come from alcoholism. Treatment depends on willingness to change, and that trait today ran the spectrum from having quit to wanting to die drunk and soon.

Two patients suffer from bipolar illness but came in for something else.

Three needed notes approving them back to work. Two asked me to write slips containing little truth, and I declined.

Two patients have puzzling clinical pictures. I don’t have to know everything, all I need to know is how to find someone who knows more than me, and I sent both patients to specialists.

The clinic manager plans to make scheduling changes, staggering start times for the docs and the Nurse Practitioner, running clinic through the lunch hour, and perhaps starting night hours. Details have to be worked out, but, as one of my colleagues observed, and gave me permission to quote, 100% of the ideas you didn’t try will fail.

I walked back to the room at lunch, ate some very tasty leftovers, and did some last-minute packing.

Back at the clinic I tried to catch up on documentation while I cared for patients, and reviewed lab, x-rays, and consults. Outside, the fine clear day clouded over, and the snow piles continued to melt.

Patients expressed dismay when I told them that Immigration decreed that to keep a relationship good enough to return I would have to leave on May 1. Actually I said that Immigration was kicking me out, but they’d probably let me come back in October.

In the long northern afternoon, Bethany and I loaded the car and headed to Prince George. Just outside of town we saw three mule deer grazing by the side of the road, and a hundred kilometers further on, far off at the edge of a flat marshland, we saw a cow moose with her calf.

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Denver Panhandlers, Then and Now.

September 28, 2015

On the street they reach their hand out

It’s money they’re talking about

If the world is a stage,

They’re here to beg,

They have problems, of that there’s no doubt

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

Most docs finish med school with crushing debts, I finished with great poverty skills and a 2 year obligation to the Indian Health Service (I stayed 5).

I did my pre-medical education at University of Colorado at Denver, at the time a commuter college with no dorms and no parties.  Paying for your own education brings out the student’s motivation.  My classmates had other employment and wanted better.

Lower downtown Denver at the time had just renovated its Skid Row around Larimer Street with specialty shops, but the bums, drunks, and prostitutes still frequented the neighborhood, occasionally drifting away from the pawn shops to the campus.

In those years I rode my bicycle everywhere, and I confronted panhandlers only when my bike broke down and I had to take the bus.

I returned to Denver for the American Academy of Family Practice’s  FMX, a convention for continuing medical education (CME).  We drove in from Iowa over the weekend.  We visited family.  The classes start tomorrow.

We walked from a very nice hotel to a silversmith’s on Larimer Square.  I’ve known the owner for 40 years now.  We walked down the 16th street Pedestrian Mall, past the panhandlers.

During my pre-med days a lot of young people found themselves on the streets because of lousy economic opportunities and generational alienation, they had good mental health.  They figured that the difference between no pay and minimum wage didn’t justify 40 hours of structure.

But at the time a lot of Indians came off the reservation to drink heavily in Denver (the sober ones, the vast majority, stayed on the reservation, giving the non-Indians in Denver a false impression of Indian alcoholism).  One afternoon I found myself walking down 15th Street when a Crow Indain confronted me.  “I’m just got into town,” he said, “I’m trying to get together enough for a bottle.  Can you help me out?”

He had caught me at a bad time.  I had much to learn about softening my words.  “You want me to help you out?”  I exploded.  “I’ve got a quarter in my pocket and I don’t have enough to buy a patch for my bicycle tire because I used the last one this morning and I got another flat this afternoon.  I haven’t eaten since 6 this morning and I don’t have enough for the bus.  No, I can’t help you out.”

He was taken aback and reached into his pocket, offered me half of what he had.

Humbled, I took enough to buy myself a new patch kit.

The street people look better fed but less washed than they did 40 years ago, and not an Indian among them.  My years in the Community Health Center softened my reaction to those who beg for money.  I have treated so many mentally ill that I appreciate the overlap between bipolar, schizophrenia, and substance abuse.  Most but not all the people I saw asking for money had the bizarre affect of schizophrenia and the twitchy gait of the overmedicated.

I gave some money, I didn’t give to others.

I can afford it a good deal more than the Crow who helped me buy a patch kit.

Iowa house calls, back to Pennsylvania

August 7, 2015

For a house call I went to a store
Then expected one or two more
To come to my house
So I said to my spouse,
They’ll come in through the front door.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

While home in Iowa last week I made a couple of house calls.

One patient owns a business I frequent, and had called me when we were both on the way back to Iowa. Our professional relationship dates back well into the last century. We have watched each other progress professionally and socially. He gave me the go ahead to write the entire visit in this venue as a record, but, for the same reason I conducted the interview on the deserted freight dock and the exam in the store’s quietest corner, I didn’t. At the end, he personally helped me with my selections and would not accept money for the transaction; nor would I accept payment from him.

Another friend has had a problem building for months; we agreed on the next step: the specialist.

The garden has come in, and Bethany and I snacked on the first of the tomatoes, cucumbers, and green chiles; We invited company for supper on Friday. For a side dish, I cut sweet corn from the cob, added red onion, roasted green chiles, lime juice, and olive oil.

I took call for my Community Health Center the weekend. One patient discharged from peds on Saturday and one admitted on Sunday,far cry from a census demanding two docs to round both mornings, with one up all night to take admits and calls.

Tuesday found us back in Pennsylvania, at an Urgent Care, working 12 hour days, but this time we can walk from the hotel to the clinic. I like the medical record system. I can whiz through documentation for respiratory problems, but skin and musculo-skeletal problems need more narrative because no two are the same. A disproportionate number of patients come in with poison ivy.

Urgent Care, by definition, doesn’t include ailments that need follow-up or CT scans. I sent a number of patients each with suspected heart attacks, blood clots, or kidney stones to the local ER. People with bipolar disease tend to have very real, severe physical problems. I can treat those injuries, but getting at the root cause falls outside my scope of practice.

To those patients who come in, for example, with weight loss (now into the double digits working for this client) I say, “This is not normal, but there is a limit to what can be known an hour, and there is a limit to the lab we can run in Urgent Care. You need a primary care provider, and here is a list of labs that he or she might run.”

Nor can I effectively treat rheumatologic problems, but rheumatologic patients come to see me nonetheless. From time to time I run into people on Enbrel, and then we generally have a happy support group meeting. We talk about how the drug changed our lives; how, coming out of the pain we could engage emotionally with our families; and about how, outside the pain relief, we just feel better; (I feel better now than I did at age 18).

If I talk to a back pain patient on opiates, I tell them how the medication inhibits their own ability to make endorphins and perceive endorphins. Some express shock and amazement, and some just want me to prescribe the Norco, because “it’s the only thing that works.”

The root that Mayo missed: whittling down the med list

May 18, 2015

Schizophrenia should not be a death sentence

May 1, 2014

Even the worst of the cynics
Support the function of clinics
It’s a seasonal flow
They come and they go
The homeless bipolar schizophrenics

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 for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I just returned from my second locums trip to Petersburg, Alaska.
The young man I talked to in the clinic recently brought a distressingly familiar story; because so many have similar tales I can talk about the non-unique elements. From out of town, he couldn’t give me a good reason he had landed in Sioux City; he had no work or money and the word “tenuous” described his housing arrangements. As we talked the contradictions in the history started to add up, but I carefully avoided bringing inconsistencies to his attention.
I won’t discuss his “admission ticket,” the physical illness he described came second to his main problem.
A long, involved medical history with improbable descriptions of other health care facilities, led me to conclude that he maintained an uncertain relationship with reality, and, eventually, he mentioned his history of schizophrenia.
My 22 years as a co-owner of an upscale clinic brought me little contact with schizophrenics, but my current position has. Our facility cares for most of the schizophrenics in the city.
I have learned that schizophrenia, bipolar disease, and substance abuse overlap each other with terrible frequency. Most schizophrenics smoke, and trying to get them to stop ranks with trying to stop the tides. The majority of schizophrenics have difficult-to-control diabetes.
We have drugs to treat the bipolar, the diabetes, and the smoking. Yet we lack good, effective treatment for the basic disease process, where a person’s thoughts loses touch with reality.
(One very effective drug, clozaril, shows dramatic improvements not only in symptoms but functionality; the worst side effect, occasional and unpredictable bone marrow shut down, makes it too toxic for all but the most severe cases.)
Our society has failed our mentally ill. A Republican President with bipartisan support closed the mental hospitals and dumped the patients onto the streets. They form a disproportionate percentage of our prison and jail population and a majority of the homeless. Unable to cope with the real world, they can’t hold jobs, manage money or maintain interpersonal relationships.
If someone in our town stumbles out from under a bridge and into a clinic, they stumble into our clinic. They truly can’t afford to pay for their services.
The most conservative, fiscally stingy, small-government supporters I know agree that schizophrenia should not be a death sentence.
Some of my schizophrenics can maintain a semblance of a normal existence with regular medication; a few can manage part-time employment. But many just keep drifting, north in the summer, south in the winter.
I do what I can for them, recognizing the fleeting nature of the relationship.

Let’s see what happens.

July 27, 2013

A matter of prognostic projection

When it comes to a diagnostic question

My pain management skills

Involve very few pills

And no longer my Enbrel injection

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

During my senior year of medical school I arranged to get credit for an elective rotation in acupuncture in January of 1979.  I studied under a very smart non-Asian internist for a month, and learned the vocabulary and the rudiments.

Before I had passed any Boards or actually obtained a license, I did acupuncture on a friend in a time crunch.  I applied a needle in each shin, close to the knee (the name of the point is Su Zan Li, but its nickname means three villages).  He responded well, and worked with tremendous efficiency for the next 9 days, turning out top-notch work.  The bottom dropped out of his energy three days later, and he slept for the next two days.

In retrospect, I had precipitated a hypomanic episode; his bipolarity would not be diagnosed for many years.  Nor did I realize the enormity of the power of those two needles for decades.

High-quality research with acupuncture showed mixed results.  A study published in a major journal demonstrated very good results in treatment of the most severe alcoholics (regretfully, the study didn’t detail exactly where needles went nor how they were placed).  Another, published in JAMA, showed acupuncture and sham acupuncture equivalent in the treatment of migraine.  Many docs point to that study and assert acupuncture has no validity; I look at the same data and conclude that you don’t have to be much of an acupuncturist to treat migraine; put a half-dozen needles anywhere you want and not very deep, on a regular basis and at the end of a year the patient will have half the migraines he/she used to.

I went to my acupuncturist today for a session because I’ve been off Enbrel for three weeks.  My sacroiliac joints haven’t fused despite my age, leading my rheumatologist to question the diagnosis of ankylosing spondylitis.  He would like to see if my sed rate (ESR) and my C-reactive protein (CRP) go up in the absence of therapy.

I can hope for a misdiagnosis, or for news that my disease has burnt itself out, but as the days go by the pain in my spine grows.  I’m now relying on the pain management skills I developed between 1967 and 2000, when I got my first injection.

I can do a lot of things to bring down the level of pain a notch or two; I can’t do anything to make the pain go away completely.    When I walked away from the acupuncturist/chiropractor’s office the pain between my shoulder blades had faded by about two-thirds, and I could sneeze without grunting.

Now I have to work on my sleep pattern.

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.

Short call on Labor Day weekend

September 3, 2012

Labor day spent making rounds.

You wouldn’t believe the diagnoses I found!

It wasn’t quite call,

I avoided a brawl,

And sent four to their homes out-of-bounds.

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

Our hospital service has grown to the point where two docs get assigned every weekend, one each for a long call and a short call.  I drew the short call this holiday weekend, not the same as the short straw.   I requested, and received, assignment to my preferred hospital, where I’ve done morning rounds now for four days. 

My natural tendencies wake me early, but today I ate a leisurely breakfast before Bethany dropped me in the deserted doctor’s parking lot.  I printed my patient list in the doctor’s lounge at 6:58 AM and took the elevator to the 5th floor. 

I returned to the doctor’s lounge, emotionally tired, at 11:30.  I had rounded on 13 patients, each one a unique human being whose illness brings drama and irony to their lives and the lives of the people around them.  Each has a marvelous story, rich with details, triumphs and tragedies enough for a series of novels.

While I can’t discuss patients in particular, I can talk about the patient population in aggregate.

Four patients carry the diagnosis of schizophrenia.  Eight qualify as hard-core alcoholics requiring treatment for alcohol withdrawal.  Bipolar disorder (previously called manic-depression)afflicts three.

Eleven of the thirteen didn’t quit smoking soon enough, such that they required treatment for nicotine addiction or emphysema or both. 

More than one has chronic kidney failure necessitating dialysis. 

Others had cancer, HIV, depression, gallbladder disease, broken bones, dementia, urinary infections, lupus, and coronary artery disease.

The nurses on the psych floor warned me about a violent patient after a near confrontation.

I didn’t even bother to count the number of patients with the garden variety problems of diabetes, high blood pressure, and high cholesterol.

I had to deal with two patients with adverse drug reactions, their hospitalizations complicated by the very medications their doctors ordered.

I discharged four patients and dictated their discharge summaries while leaning my back against the wall; I wrote prescriptions for three of them.

One of those represents a triumph of medical care; we cured the problem and sent the patient home in less than 72 hours.  Such satisfaction comes rarely and I relish it when it does.

The doctors’ lounge stood deserted at noon on Labor Day, and I power napped ten minutes before the next task, reviewing transcriptions.  I had 37 in my queue.  After that I dictated six discharge summaries.

I left the hospital at 12:40PM, the rest of a fine summer day right in front of me, and headed home for lunch.

Rounds from Dawn to the Newborn Nursery.

July 26, 2012

 

Sunrise in the ICU

I started the day making rounds

Checking the lungs and heart sounds 

 

It started with dawn,

Where has the day gone?

Beauty is where beauty is found.

 

 

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 started so early that when I saw my first hospital patient, a perfect sunrise broke as I entered the room on the top floor of the hospital.  The water content of the atmosphere blocks the view of the sun most days till the red disc has ascended well above the horizon, but with the hot dry weather we’ve had, there was the sun, just peeking up.  And the ICU offered a spectacular view of the city in the morning.

The patient couldn’t speak and could barely respond.  Even if the patient can’t talk, I speak to him or her, tell them who I am, the date, where they are and why they’re there, and I try to give a few headlines from the news.  In this case I called attention to the phenomenal sunrise, but the patient didn’t look. 

From the ICU on 6th floor I went to see a new admission on 5 Medical, and discharged a patient who had recovered enough to go home.  Striding down the corridor to the opposite end of the hospital I came to 5 Behavior Health, the psychiatric service.  I did medical consultations on two patients admitted during the previous 24 hours.

The psychiatric portion of the service consists mostly of people who didn’t ask for their problem but got it anyway.  A surprising number of schizophrenics also qualify as bipolar.  More than 90% smoke, and a lot of them come down with type I diabetes as their pancreas withers away.  They lose years of life.  A majority of schizophrenics also have drug and alcohol problems, and they can’t learn from their mistakes.

Our society has failed our schizophrenics.  At one time institutionalized, they were turned onto the streets when the institutions closed, and went right into the criminal justice system.  The ones who stay out of incarceration use a lot of health care.

Fourth floor holds the oncology (cancer) and surgery nursing units on the south.  Contrast being the essence of meaning, I talked to those who know they have no cure and to those with a reasonable expectation of cure.

The pediatrics wing sits on the north end of the fourth floor, and I had no patients there.  Fewer and fewer children need admission to the hospital as the years wear on.  Vaccinations have prevented most measles, mumps, chickenpox, polio, rotavirus, pneumococcal, and meningococcal disease.  We see a tenth of the croup that we used to.

On the third floor orthopedics unit I did two consultations for people after total joint replacement, and on the second floor I took care of two newborns.

Death, the ultimate drama and the ultimate irony, came to three of my patients during the day.  One in middle age died surrounded by grieving family.  One went unexpectedly and alone.  A third died so old and full of years that few remained to note the death, though many, on reading the obituary, will sigh and reflect on how the passing impoverished the world. 

 

 

Blog reopened after a year on the job.

July 5, 2012

I find my job a delight

Even when working at night

On this I won’t budge,

I’m a doc, not a judge,

And there’s always something to write.

I have decided to reopen my blog after a year’s absence.  I miss writing, and I miss the immediacy that comes to my life when I go through my day thinking about my post.  I’ve been at my new job a year now.

My workplace runs on teamwork; I’ve never been any place where people seek out so many opportunities to help their coworkers. 

Our patients have few resources; 50% have no insurance, 35% have Medicare or Medicaid, and 15% have commercial health insurance.

I see a lot of schizophrenics, people whom our society has failed badly.   I’m sure if they could push a button and come to a closer contact with reality, they would.  As it is, they hear voices when they don’t take their meds and sometimes even when they do.  An extraordinary number also carry a diagnosis of bipolar.  Almost all smoke, and, given enough time, almost all develop insulin dependent diabetes. 

I find it easy to avoid judging the schizophrenics; they did not ask for their problems.  The less I judge my patients, the more energy I have at the end of the day.

We have so many patients from Ethiopia and Somalia that we have Oromo, Amharic, and Somali translators, and I’ve learned to say Hello, How are you, and Thank you.  Mostly hardworking, family oriented people, they came here after unspeakable horrors.

Many of the people who come to my clinic have been behind bars.  I don’t ask them why.  After all, I did not train as a judge.  Those folks have done their time and my job, as I see it, demands that I focus on what can be done in the future, not what has already passed. 

I start Mondays with hospital rounds till noon, then clinic till 8:00PM.  I’m on call 35 Tuesdays per year.  Most call nights I work straight through till after 9:00 PM.  I start Wednesdays at 7:00AM and finish around 6:00PM. 

I have Thursday off, along with Friday, Saturday and Sunday if I don’t have call.  I still put in 48 hours weekly.

Yet I worked no more than two days a week in the last six weeks, which I found unfulfilling.  I arrive at work Monday mornings cheerful and happy to be back, and I go home on Wednesdays ready for the weekend.

Saturday/Sunday call a year ago ran to fewer than 10 patients between two hospitals, but practice growth led to mission creep, and now a hospital census can run upwards of three dozen.  At any one time, we usually have three patients in liver failure, and three in active alcohol withdrawal.  A surprising number of non-alcoholics end up with cirrhosis.  About half our hospital patients also show up on the dialysis service.  Mental health census averages 5. 

Our patients get sicker younger than any patient population I’ve seen before, which surprisingly, gives me more hope.