Posts Tagged ‘clinic’

A move, a short commute, and two puzzling patients.

April 20, 2011

Sometimes it’s up to my care

For an unusual case here or there

     With symptoms so weird

     I’m left scratching my beard

For the patient has something rare.

 Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  After a six-week assignment in Barrow, Alaska, the northernmost point in the United States, I’m working on the North Island of New Zealand. 

Bethany and I moved into the doctor’s quarters attached to the Matakana clinic.  Much like a parsonage, it features a kitchen, lounge (=living room in the U.S.), dining area, utility room and closet.  The yard has four citrus trees, which fruit will not ripen during my tenure, and a tree with ripe fiejoas. 

I won’t miss the drive from Leigh with the narrow, noisy, winding road where speeds of 40 kilometers per hour (24 MPH) amount to overdriving the visibility and traction and risking a spectacular flight into the sea.

My commute consists of stepping through a door into the clinic area. 

Few people do the math when it comes to their travel to and from work; perhaps Jack makes $12.50 per hour, but if he works an 8 hour day and has a one hour drive each way, he effectively makes 20% less than Jill who lives next door to the shop and does the same work.

Today I had the pleasure of working all day and never being more than fifteen steps away from my bedroom.

I cared for people aged six to eighty-five; most of the business, as always, stemmed from tobacco and alcohol.  Superficial skin infections, here called “school sores”, continue to be a major source of business. 

Several people came from the UK, a few came from Pacific countries.  I talked to one, not a patient, who had grown up in Matakana, and remembered the clinic building when it was home to a family with two deaf parents.

I took care of more than one puzzling patient; both presented with fatigue.  Both concern me, one more than the other. 

Sometimes a patient has a rare problem, or a common problem that presents uncommonly, or limited communications skills, but in any case presents an intellectual challenge.  My chance of making the patient better is inversely proportional to the number of years the patient has had the problem and the number of doctors the patient has seen.  Sometimes I nod sagely, reassure the patient that, for example, Mayo Clinic has done a fine job of making sure there’s nothing really serious.  From time to time, I finish convinced of a major disease ravaging the patient and equally convinced of my ignorance. 

I anticipated a difficult member of the “worried well,” and asked the nurse to sit in on the visit.  In less than three minutes I felt myself to be in the good company of a range of doctors who had missed a significant diagnosis.  I found several abnormalities on physical exam, but nothing straightforward. 

Galileo said he had seen so far because he’d stood on the shoulders of giants.  I told my challenging patients that if I found a rare diagnosis, it was because the other docs looked in the reasonable places first and I knew where not to look.


Why I do and I don’t do housecalls

March 6, 2011

The number of docs is deficient

Though the need would appear quite sufficient

    If you ask me why is it?

    I’ll say a home visit

In the end remains inefficient.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  I just got back from a six-week assignment in Barrow, Alaska, the northernmost point in the country.

My father made house calls.

He graduated from medical school sixty years ago, when women were systematically excluded from the profession.  At that time, a physician finished an internship, hung out a shingle, worked solo practice, and took call 24/7/365. He made hospital rounds in the morning, saw patients through the day, and, after supper, made evening rounds and house calls.

Our 1960 Ford Falcon had a spotlight, like the police used, so he could see house numbers at night.

He used to take me with him, to the hospital and to patients’ homes, when I was in elementary school.  I waited in the front lobby of the hospital at a time when it constituted the main ingress, but I got to go into houses with him.  I remember the time spent with him, I don’t remember the time spent waiting.  I can see his stethoscope hanging by the front door, his electrocardiogram machine in the back seat, and his doctor’s bag with the blood pressure cuff and medications like Demerol , penicillin, and digitalis.

But in an era of generalists, my father specialized first in Internal Medicine, and then in Cardiology.  ICUs and CCUs didn’t exist, and before revascularization, statins, and beta blockers, patients with heart attacks frequently received treatment at home.  Looking back, hospital care at the time differed little from a doctor making a home visit.

I have done house calls, but I probably don’t do more than twenty a year. 

When I worked for the Indian Health Service in New Mexico, the government tore down a perfectly functional clinic and paid me to do nothing until the new clinic was built.  After two weeks I realized I had started to be mean to my kids and I hijacked the Community Health Nurse to take me on hogan visits.  I learned a lot about my patients I wouldn’t have otherwise known.

Mostly, when I care for a patient in the home now, I do so more for my convenience than for the patient’s. 

Once, when a heavy, wet snow closed the city and the clinic down in the middle of the day, I got a page from a patient with bad lungs, heart, and balance just as I was about to exit the building.  In the days before common use of cell phones, I turned around, shucked off my parka, and returned the call.  After a brief conversation, I knew I lacked certain key items of information from the physical exam to make a good clinical decision, and I didn’t want to endanger the patient by making him go to the ER in bad weather.  I asked the address, and saw that the patient resided between my clinic and my home. 

I arrived fifteen minutes later on roads I could only negotiate with four-wheel drive.  Fifteen minutes after that I asked for a towel as I washed my hands at the kitchen sink, grateful for the warmth of the water and a ritualized end to the visit.

Today, I talked with a friend and patient who lamented the absence of my house calls.  We talked about how inefficient such delivery of care is, and how we don’t have enough doctors to make the service available on a regular basis.

It’s rare that I do house calls now.  Documentation suffers the longer one waits to make one’s note.  Still, I have a dedicated stethoscope and otoscope in my car.

But I don’t carry a black bag with Demerol, digitalis, or penicillin.

Thawing snows, faces startle while looking at maps, and preparations for the end of my walkabout

March 5, 2011

I went out one day in the spring

With great hopes, but here is the thing:

     Any woman or man

     Can come up with a plan,

But who knows what the future will bring?

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  I just got back from a six-week assignment in Barrow, Alaska, the northernmost point in the country.

Friday morning Bethany and I woke up to the sound of birds singing outside the open window.  Not that we’d opened it all the way, but we couldn’t leave a window open if we’d wanted to in Alaska..

An air of familiar unreality followed me while I drove around town, getting ready for the next journey.  Liquid water lay in patches on paved streets where stop lights functioned in seriousness, no whine of snow machine engines permeated the air.  Jokes, not warnings, mentioned polar bears.  Two hundred million years of sediments cover the ocean floor, rather than the Chukchi Sea topped with sea ice.  Trees lined the streets, melting snow drifts decorated lawns.

Less than twenty-four hours after leaving Alaska, I made calls on patients in a nursing home half an hour from town.

On Friday afternoon I sat and talked with two docs in a room at St. Luke’s Hospital.  They had both been to Haiti several times, one had been to Africa.  We swapped stories about medicine in the bush.  They had more heroic stories to tell, after all, I’ve been working in the US in the 21st century, and I got paid.  They still let me do the talking.

I frequently ask if people know where Barrow is.  If a computer sits close by, I have them put onto the browser and type in Barrow.  Then I watch their faces, as I say “Zoom out, zoom out.”  The eyebrows go up and the smiles breaks.

I enjoy watching the startle.

One of those doctors will be the clinical director at the facility where I’ll be working when I come back.  He’s a good leader, he’ll find ways to use my interests and strengths. He’s looking forward to having a Spanish-speaking doctor on staff.  I’m looking forward to teaching responsibilities and hospital work.  He and I share a sense of what we think medicine’s mission should be and where we think the system is going, whether we like it or not. 

As the sun started dipping towards the horizon, I went downstairs to the Medical Staff Administration area.  Announcing that I’d be returning in mid-June, I asked what would be needed after my leave-of-absence ended.  The credentials committee will meet, I was told, in May.

I’ve sat on that committee for the last couple of decades.

Outside, with the afternoon again grown chill and windy, the city smelled like early spring.  I went to the clinic where I’ll be settling in come June, to talk to the credentialing and Human Resources folks.  They’ll have my ID card on Monday, also a contract.

I feel like I’ve been playing hooky for the last nine months.

Everywhere I went people greeted me warmly, wanted to know where I’d been and what I’d been doing.

At the Mexican grocery I picked up mangoes and avocadoes.  When I got home, while two salmon fillets smoked on the grill I peeled and chopped the fruit,  cut up half a red onion and squeezed in a lime.

In the evening, friends came over for our Friday potluck, still the highlight of my week.

Advising a potential doctor after a good day in the clinic

October 28, 2010

I said to a friend of a friend,
Consider the time that you’ll spend
    And the cash you’ll be burning
    For medical learning
And the terms of the Federal lend

I take care of patients and I cannot write identifying information. They are male or female or confused; they do or they don’t work, they are or they aren’t students or teachers or either or neither or both; some drink to excess; many smoke; each is a part of a family unit and has a social context. They all have feelings; the adults all have sexuality. Each has urges to evil and good in various strengths and directed with differing degrees of mastery.

Today I saw patients for colds, coughs, pink eye, sports physicals, sore throats, urine infections, STD’s, hives, ankle sprains, ringworm, and well child checks.

One patient’s family includes three generations of jockeys, one of whom rode the Kentucky Derby three times (I have permission to include that information in this blog).

My patients bore Polish, Hispanic, Irish, Scots, Czech, English and Indian last names; some had mixed Native American facial features.

One parent and child interrupted each other constantly despite a great deal of apparent love.

I gave advice about nicotine, caffeine, alcohol, trampolines, foot odor, ear wax, seat belts, sleep, exercise and diet.

One person, betrayed by a lover, wept.

Two families were affected by alcoholism.

The clinic today opened at noon and we went till eight.

When I got back from work I called a friend of a friend, actively considering a medical career. No matter what you think medicine is, I said, it will not be that when you finish your training; it will have morphed into something we cannot even imagine. No career holds more honor, few have more job security. These things will not change: people will get sick, sick people want to get well and they do not want to see unfamiliar faces; healers will hold a high place in society and they will be fed.

Becoming a doctor requires an investment of two years for premed, four years for med school, and three years for residency; the money invested pales in comparison to the time. Government programs that finance the education demand payback on a year-for-a-year basis, and pay a fraction of what could be earned in private practice.

I had a National Health Service Corps scholarship to medical school; they paid tuition, books, and a stipend.  I worked in the Indian Health Service three years past my obligation because my time with the Navajo enriched my life beyond measure.  When I left my income doubled every six months for a year.

Medical school changes the person who enters. Someone who seeks only riches will either drop out of the program or will change their attitude; the same can be said for those motivated purely by altruism.

The doctor who doesn’t put first things first in his or her own life won’t last in the profession. The doctor who neglects physical needs, such as eating, sleeping, human relations, and medical care, will burn out.

Pick a specialty, I said, based on what you’re good at and what you love. Don’t go into something because you admire a particular specialist.