Weekend Call: transitional chaos, a colleague retires, and another teaches.

The hospital’s making a switch,

The electronics are finding a niche

I don’t think it’s strange

I was there for the change

Unexpected is always a glitch

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 agreed to take call this weekend to help out a colleague and coworker.  Had I thought ahead I might not have.

One of our hospitals made the shift from paper to electronic medical records (EMR) at midnight between Saturday and Sunday.  Only the Wednesday before the switch, when I had already committed to taking call, did I realize I would be on board for the transition.

All change inherently involves chaos; nothing ever works out the way you planned.  The greater the change or the faster the change, the more that the Law of Unintended Consequences applies. 

One of my colleagues, an emergency physician with whom I have worked for the last two decades, chose this time to retire; he didn’t see a future on the far side of the learning curve.  At 5:30 in the morning he called me about a patient needing an admission.  I listened to his presentation, accepted the admission, and asked if it constituted the last admit of his career.  (It doesn’t make a difference, but the clinical problems included diabetes, dehydration, and diarrhea.)

It had.  A small silence passed between us, memories filled with drama and irony.  I recalled my year of walkabout and the last day I spent at the clinic.  Much was said and little spoken.  “Well, it’s been an honor,” I told him.

I could hear his smile in his pause.  “Thanks, Steve,” he said.

An hour later, with my unfamiliar-looking census in hand, I arrived at the 6^th floor ICU to spend 15 minutes with the patient and the next 45 minutes doing the documentation.   To my regret I stooped to occasional truculence and sarcasm aimed at the nice lady who wore the fluorescent yellow vest of a super-user, someone educated enough in the system to help those just starting.  I pointed out that I had 15 patients on my list and at that speed I wouldn’t get home till ten in the evening.

The next floor down presented compound problems of two new admits and two other patients in the surrounding context of rampant chaos.  

I found Dr. Tan (who gave me permission to write this) in the position of super-user.  We have worked together for close to 20 years.  With a background of a great working relationship based on clinical respect and trust, she gently ushered me into esoteric information pathways.  My second patient took me 45 minutes and my third patient took me 30. 

Our practice has too many hospital patients for one doctor to round on through the weekend.  One doctor takes call and sees patients at one hospital; the other doctor rounds at the other hospital, then goes home.  I take pride in being able to finish at one place and help out the other doc across town, but noon today found me done with the 6^th and 5^th floors and the rest of the hospital to go.  Knowing I wouldn’t possibly finish in a reasonable time frame, I broke for lunch. 

No food today graced the doctors’ lounge, but the cheerful mood verged on hypomanic.  Contrast those smiles to the last time I saw a hospital go digital and grim faces drip frustration.

At home I relaxed my way through soup and a nap. 

I finished the 4^th floor and arrived in the Newborn Nursery at 3:00 PM.  Immediately confronted by logistic problems involving ordering things for circumcision, I glowered.   In 30 years I had never had to do such a thing, only with the current new digital system.  I expressed a desire to be done with the procedure by 5:00.  Better to be happy than right. I finished half an hour later.

On the way out I reported a large number of computers on the second floor incompatible with the new system.  Or so the nurses thought.

All in all, I had had the best day to transition, not the worst.

 

 

Something new every day, great food, retirement plans

Eventually I hope to grow wise

Every day still holds a surprise

            I note with precision 

            When I did circumcision

A newborn with tears in his eyes

When a doctor sees a hospital patient with no intention of dictating a note or sending a bill, he or she calls it “social rounds”.  Doctors do it a lot but we do it less and less as the years go on.  Hospitalists do much of the hospital care.  Only in the USA do outpatient doctors also do inpatient medicine.  Bethany and I stop up to see a friend at St. Luke’s, and we sit with him about 45 minutes till he is ready to go back to bed.  I stash Bethany in the doctors’ lounge and I go back up to newborn nursery.

I called ahead to make sure the baby would be there at the right time, so, of course, he isn’t.  I look over the chart and there is no circumcision permit signed, so I grab a stethoscope and I go examine the mother, who is doing very well.  I confirm that she wants the baby circumcised, I go over the consent form with her, and I go back to the nursery.  I examine the baby, then I have the nurse get him ready for the procedure.

Babies hate cold and they hate being tied down, and they cry during the circumcision.  In fact, they cry before the procedure.  This one is no exception.

What is exceptional is that he has tears.

Newborns cry, but children usually don’t make tears till they’re at least six weeks old. 

I graduated medical school in 1979 and I started seeing patients in 1977, and I have seen thousands of newborns.  Today is the first time I saw a one day old infant with tears.

I have a very long memory and I’ve seen a lot of patients and if it’s a day with patients I will see at least one thing I’ve never seen before.  Especially my clinical afternoons are strange.  Sometimes things get so weird that I don’t even believe them.  I used to say, “This afternoon couldn’t get any stranger unless Elvis himself actually showed up.”  I don’t say it anymore, I’m afraid it will happen.  Many of those things I will not write about because I can’t write about them without breaking confidentiality and because I will not be believed.

After the circumcision I dictate my notes, order a bilirubin for the slightly jaundiced baby, and ride the elitist, Doctor Only elevator down to the doctor’s lounge.

Twenty two years ago before I was betrayed successively by my back and my ankle I didn’t use the elevators because they were too slow.  Of course the doctor parked much closer to the patient back then.  Rounds were quicker because the minimum time investment was smaller.  As time has gone on the architectural distance between doctor and patient has steadily grown (this is a nationwide trend).  During the same interval, doctors going to hospitals spend more time in hospitals and less time in offices or clinics. 

Back when I started taking elevators, I eschewed the one reserved for docs as being elitist.  I have since embraced it, and I have come to cherish the time I spend waiting for and riding in elevators as being some of the few quiet moments of my day.  I don’t even try to multitask in them any more.

Bethany is watching a crime show on TV when I walk in.  We talk for a short time, then we drive to South Sioux City to meet a colleague for supper.

I have to wrap my colleague in mystery because the career plans we discuss are not yet public knowledge, I will not even reveal gender.

It is neither secret nor surprise that I know every doctor in Sioux City.  It would not be out of the ordinary to sit down with any of them to have this talk we have planned.

The colleague wants to move someplace warmer and sunnier.  I agree that such things are desirable, but my non medical social contacts have become a part of who I am, my social world; my career plans don’t include moving.  The colleague talks about an offer, the details of which have not been firmed up, for about half the current gross income.  We discuss how to figure cash value of perks.  We talk about state and federal income tax.

We also discuss the concept of marginal cost benefit.  Taxes have become an disincentive to work, we agree.  I talk about some of the offers I’ve seen which would cut my work time by half but give me 80% of my disposable income.

We talk about the owner/employee tradeoffs.  We agree we want to have more time, that as we age the time becomes more important than the money, that working for a long time is desirable, and that most doctors work at unsustainable paces. 

The food is exquisite.  The company is wonderful, the conversation clear, and the pace at which we eat is leisurely.

Thirty years ago during residency, I learned that, if you’re in medicine, there are three things you should do every time you get the chance, because you don’t know when you’re going to get the chance again: eat, sleep, and pee.  Since then I have gotten very good at bolting my food.  Usually I eat without tasting, a denial of one of the basic pleasures of life.  But tonight I have no trouble eating at a leisurely pace, a wonderful contrast.

We enjoy dining out but the food at home exceeds the quality of most places.  If we travel to small towns we’ll have no trouble having fine dining.

On the way home Bethany notes that the streets are eerily dark, and then we realize that the power is out.  Here and there a few houses show up as islands of light in a sea of darkness.  A few people sit in cars outside their garages, with motors running and headlights glowing.

Most people in Sioux City either don’t lock their front doors or don’t carry a front door key because most people come and go through their garages.  Unusually for us the front is locked, and the garage door opener is powerless. 

I surprise Bethany with my front door key.  We empty the upstairs freezer into a cooler and put the cooler in the snow bank off the front porch.

Without power, I have no connection to the Net, but my laptop obeys my touch and I write till it runs out of juice, while Bethany reads using my LED headlamp. 

Which is why today’s posting is a day late.