Posts Tagged ‘diabetes’

Road Trip 8: Fantasy bare-bones formulary

November 18, 2014

For our tools, the meds are the core
I used to use way less than a score
Is a need demanded
Drugs that were branded?
Saying “no” is really a chore.

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, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. I just returned from a road trip, to visit family and friends and attend a Continuing Medical Education conference.

After the Continuing Medical Education ended, two daughters and one son-in-law accompanied me to sushi lunch, followed, naturally, by dessert.

The ice cream parlor sat in a building that had previously housed a drug store. Closed in 1979, the interior stayed intact until the building sold to new owners who rehabilitated it and decorated it with stuff that had remained from the pharmacy years.

We observed the lack of variety in the drugs that graced the shelves, and soon the two physicians (my daughter and I) dominated the conversation with the question: If you were Minister of Health for an impoverished, small island nation, what drugs would you have on your formulary if you could only have twelve?

We started with pain relief, my younger colleague wanted ibuprofen and acetaminophen (Motrin and Tylenol); and for high blood pressure lisinopril and metoprolol. I agreed with acetaminophen and lisinopril, allowed as how I could live with metoprolol but would prefer carvedilol (in the same class of high blood pressure meds, but also useful in heart failure), and didn’t want ibuprofen at all. “Too many side effects,” I said, “Ulcers and kidney damage and such.”

Diabetes, I declared, should be met with metformin; she would prefer a long-acting insulin. And I could see her point. A long-acting insulin would at least keep the Type I diabetics alive.

I kept looking over her shoulder at the few shelves lined with medication bottles. I remembered, during residency, checking out the 1979 Physician’s Desk Reference and comparing it to the 1980 edition and thinking how small the earlier version looked. With more than 4,000 pages verging on folio size, the current edition dwarfs both put together.

What about antidepressants? We agreed on citalopram. Antipsychotics? Haloperidol (brand name Haldol). Sleeping pills? I voted for trazodone as a triple function drug, useful for depression, chronic pain and sleep.

For antibiotics, we agreed that if we only used amoxicillin sparingly, resistance to it would fade. I wanted another one in addition, such as doxycycline or azithromycin. And I shook my head; doxycycline has gone from $.04 per pill to $3.50 per pill. I asked, What about mupirocin (a topical antibiotic) but the question went unanswered.

If we hadn’t forgotten about thyroid disease, I would have suggested levothyroxine. But we finished our ice cream and went out into the afternoon sunshine. “You know,” I said to my daughter, “In the last three years, working at a Community Health Center, I know there are a lot of really neat new drugs out there, but I don’t prescribe many. Do you write for much in the way of branded meds?”

“No,” she replied, “About the only drug that’s on patent that I prescribe is Plavix (which helps prevent blood clots).” She recounted a conversation with a salesman representing Oxycontin; neither of us prescribe it at all. The rep had asserted the new reformulation made it less addictive. We laughed. A drug like that doesn’t need a rep.

During residency, I clearly remember the program director teaching us that most doctors use fewer than 20 drugs. Pick one from each class, he said, and get familiar with their side effects and their interactions. But he taught us those things before the Information Age and the Internet.

We got in the car. “What about asthma?” I asked.

“We’d have to have albuterol,” she said.

“And prednisone?”

“Yeah, I guess we’d have to have prednisone,” she said.

I suggested single 20 mg tablets scored with three lines on one side and four on the other.

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Three doctors over breakfast discussing contracts, diabetes, trauma and hearts

August 31, 2014

At breakfast sat down doctors three
The advice that we gave was for free
We talked about cases
And contractual places
And what we should charge for a fee.



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 still take short-term positions occasionally.

Three of us met on a Thursday at a popular coffee spot. Over trendy breakfast items and flavored lattes we discussed game theory and negotiating techniques.

A couple of Thursdays or Fridays per month have found us at a morning meal together for the last couple of years. We have guided each other through difficult items of a doctor’s career. We all face hard decisions for our lives and our life’s work.

We do not hesitate to give voice to good advice in the face of questionable choices, and we each have regretted not taking our own advice.

But yesterday we talked about getting a better offer. One who has no willingness to walk away from a deal has no bargaining position at all. We have all faced bait-and-switch situations; an employer has said one thing, made a deal, then unilaterally changed the circumstances. What can a doctor do?
None of us alone has more wisdom than all of us put together, and our group consciousness guides us to better decisions and actions.

We finished stronger than when we had started but we ran out of time and we still had cases to discuss. Because the business of being a doctor and the work of being a doctor are so intertwined. Come to my house tomorrow at 7:00AM, I said, I’ll make omelets and we’ll continue.

As dawn on Friday broke, I engineered quick but elaborate breakfast dishes. Jarlsburg cheese caramelized in the frying pan as the discussion started.

For reasons of anonymity, I will leave out who presented which patient.

An 18 year old female with thrush, or, at least, a painful mouth diagnosed elsewhere as thrush.
“Does she have HIV?” one asked. No, she didn’t, but that’s a good thought and the test came up negative. “How about the 3 P’s?” came the next question. Excellent, the presenter said, referring to polydipsia, polyuria, and polyphagia (drinking a lot, urinating a lot and eating a lot), the three signs of diabetes we all learned in medical school. Yes, she did; her sugar was 424. There followed a presentation about distinguishing Type I diabetes, where the patient will need insulin for the rest of her life, from Type II, where diet, exercise and pills can take care of the problem. We talked about 4 lab tests 2 of us had never heard of, and how the phone call to the endocrinologist (hormone specialist) went.

Then a case of wide-complex ventricular tachycardia with low blood pressure, a presentation classic from Advanced Cardiac Life Support, a course we’ve all taken. And after that, a death from massive trauma, complicated by legal and administrative issues and a difficult family situation.

As we ate mushrooms, onions, fresh basil, eggs and cheese, each of us filled in the human details, the heart-rending impact of disease as it ripples through the family, the community, and the hospital staff. By the time we finished we were better doctors.

Sick young men

May 5, 2013

 

In came the sickest of blokes,

He drinks, he gambles and smokes

Before he’s wise or he’s sage

He’s at such a young age

And I broke the bad news to his folks.

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.

The clinical theme of my weekend call has run into the realm of young men with very bad disease.

Any serious illness comes with a certain sense of irony and brings drama to the family context of the patient.  Advanced age lessens drama; a heart attack in an 85-year-old doesn’t carry the same emotional weight as a heart attack in a 35-year-old.

Most of these patients have problems with alcohol and tobacco, and their sum total of illnesses reflect more their life style choices than their heredity; some of the worst problems, though, showed up gratuitously, unannounced and unexpected.

So common do the three problems of diabetes, high blood pressure and high cholesterol run together that when I transfer information from one source to another the number 3 serves as my notehand for those three diagnoses.  That single digit showed up in more than 80% of the work-ups I have done so far this weekend.

But that trifecta in and of itself doesn’t lead a person to hospitalization, but the sequelae from narrowed arteries can bring on heart attacks, stroke, coma, and respiratory failure.

As the day waned and the sky darkened, I sat and talked with a justifiably worried family about a very sick young man.  The relatives didn’t hear the implication of the possibility of a fatal outcome until I stated it explicitly, and I had to endure looks that could kill messengers.

Any family conference involves a lot of questions.  Most interviews start with questions about the illness but progress more and more to issues with emotional content.  Those last parts tax my skills as an interviewee the most, but they bring me a sense of where the person fits in the web of their family; they take a lot out of me emotionally.

An hour later, In the ICU of the hospital on the other side of town, I interviewed and examined a young man who looked twenty years older than his real age.  The things the medical community had warned him about as a teenager had come to pass.  He didn’t wrestle with existential questions, nor did he want to change his lifestyle.  When I finished with the patient, I found no family to explain things to. 

A physically sicker patient in a sociologically healthier context brings a sense of tragedy more fulfilling than that of the ailing loner.   Contrast remains the essence of meaning.

 

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

March 3, 2013

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 6th 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 6th and 5th 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 4th 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.

 

 

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.

Erode away your problems, ten minutes daily

November 4, 2012

If you can invest minutes ten

Every day, not now and again,

You’ll accomplish great things,

You’ll play and you sing,

And they’ll say, “You find time?  Tell me when!”

 

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.

Erosion, the powerful force of geology, accomplishes more than cataclysms.

Sometimes I talk to young mothers overwhelmed by the mess in their house.  The child, they complain, has strewn everything possible all over the floor, and they don’t know what to do.

I explain that because children dwell on the floor and because they inherently generate chaos, the situation falls squarely into the normal category, and that trying to change the base cause of the mess ranks in futility with trying to stop the tides.

Maintaining steady erosion, I say, has a better chance of accomplishing the task at hand than trying to clear everything up at once.  Every time you pass a haven of disorder, put one thing back in its place.  If you have enough energy to sigh at the mess, you have enough energy to improve it a little.

Bethany and I started decreasing the number of our possessions 6 years ago.  We keep at it steadily, and every year we have less clutter.

One hour a day, 5 days a week, for eight weeks, separates you from the 300-word vocabulary that constitutes the basics of another language.  At the end of the first term you can make your needs known, and understand rudimentary concepts.  You won’t have fluency but you’ll have the foundation to build fluency.

In the last two years I have found practicing the saxophone 10 minutes a day more feasible and more pleasurable than the hour a day I use to aspire to. 

One can find ten minutes in a schedule easier than an hour, and ten minutes regularly brings more learning and finesse than an hour that doesn’t happen all that often.

Any activity we enjoy for ten minutes tends to extend as time goes on.  If I can get my diabetic patients into the habit of walking 10 minutes three times a week in September, by the time March rolls around I can coax them into 15 minutes at a time, and in a year or two I’ve gotten them up to 30 minutes six times a week.

When I set out to practice my saxophone for an hour, I often shorted my time.  Now that I only aim for 10 minutes, I get more out of my playing, I make more time to practice, and when I cheat, I go long, not short.

Three Community Health Clinic Doctors in an Evening Colloquium

October 5, 2012

It turns out my daughter’s a doc,

So’s her fiancee, no shock

At Community Health

You get lots, but not wealth.

Last night we sat down to talk.

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.

Our oldest daughter, Jesse, finished her Family Practice residency in July.  Bethany and I came to visit her and her fiancee, Winfred, also a family practitioner, in Tacoma.  Jesse represents the third generation in her family in medicine; Winfred the second.  Both grew up with medicine discussed at the dinner table.

All three of us currently work in Community Health Centers; my position permanent part-time, theirs full-time locum tenens.  We had a great colloquium last night.

Patient falling with urinary incontinence and memory loss?  “Normal pressure hydrocephalus,” Jesse said, even before I got to memory loss, and we talked about the handful of cases we’ve seen between the three of us.  The discussion included the human drama of the cases along with a recounting of the physical exam and the MRI.

The question of “What’s your personal best TSH?” came up.  Jesse had a patient with a 56, but once I saw a lab slip come in with “>105.”  The TSH remains the most important thyroid test; the higher the number, the more desperately the body screams for thyroid hormone.  My case dates from the last century, and I told the story, including pseudofractures, hyperparathyroidism, hypercalcemia, familial dysfunction, and bad physician communications.

All three of us serve underserved populations, which in this country means that our patients have very little money.  For a variety of reasons, poverty and diabetes go hand in hand.  Long a staple of therapy, insulin comes in a variety of strengths and costs, but none are cheap and we talked about the high cost of essential medications.  I recounted my experience bringing insulin to Cuba on a medical humanitarian aid mission.  In a small town, word spread quickly that I had brought a refrigerated package with me.  A young woman, a prostitute who worked the hotel where I stayed, approached me. Her younger brother had diabetes and couldn’t get insulin because of the inefficiencies of Castro’s system.  She made it clear she’d do whatever it took to save his life, ignoring my teenage daughter standing beside me.  It broke my heart to tell her I’d turned the insulin over to the Red Cross the day before.  Twenty years ago, $200 only bought 4 vials of an injectable medication that made the difference between life and death.

What beta blocker do you use?  Jesse knows generic propranolol rates as one of my favorite drugs, but I prescribe it mostly off label, for migraines, panic attacks, blushing, and performance anxiety.  Labetalol, which should be cheap because it’s been generic for so long, turns out to be very expensive; but the least costly one in my clinic, carvedilol, only lost its patent four years ago, and has a lots of good qualities.  All three of us use a lot metoprolol.  None of us start patients on atenolol, though we’ll keep people on it if they’re doing well.

None of us like prescribing narcotics or tranquilizers; Jesse and Winfred won’t prescribe sleeping pills at all.  Not even trazodone?  I asked, naming an antidepressant with good effects on sleep and chronic pain.  Well, they said, maybe trazodone.  How about Rozerem?  I asked.  It’s effective, minimal interactions, and no potential for abuse.  But it’s so expensive, and insurance won’t cover it.  I paused and thought and then admitted I’d given out samples but never written a prescription for it.

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.

Weekend rounds in vignettes

August 5, 2012

This morning I rounded on nine

Three of them now feeling fine

It’s only a slip

That can fracture a hip

An ankle, a neck, or a spine.

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 rounded on nine hospital patients this morning.  The oldest 86, the youngest 19, all of them had more than one diagnosis.  I can’t give identifying information about specific patients because of confidentiality, but drama and irony fill the stories of the people who fill the hospital beds.

Schizophrenia makes a person more susceptible to disease, and the disease process is worse for having schizophrenia on board.  Most schizophrenics smoke, and a frightening number acquire insulin dependent diabetes.  They face problems at the time of discharge, if they can’t take care of themselves and lack financial resources, though most have government-funded insurance.

Anyone unable to care for themselves, with no money or insurance, represents a problem for the hospital.  A lot of nursing homes would go bankrupt if they kept more than one non-paying patient, and some couldn’t afford even one.  Nonetheless, the attending physician has to round on those patients, and has to deal with Utilization Review, a committee that politely and professionally asks why the patient has to stay in the hospital at a frightful cost.

Everyone who smokes knows they shouldn’t, and most intend to quit, but I get a lot of business from people who don’t quit soon enough.  Contrary to popular belief, most smokers die of heart disease and emphysema rather than lung cancer. 

Some people arrive in this world with bad diseases that they didn’t ask for.  Some give up hope at a young age, and bring me a lot more business than those who decide the make the best of a bad situation and take care of themselves as best they can.

Mathematical ability dissolves in alcohol, nobody can count after they’ve had more than two.  Which leads people to think that alcoholics lie, when in truth they’re just lousy estimators.  Continued alcohol use with hepatitis C, viewed by many doctors as an active death wish, leads to cirrhosis and a horrid, stinking death, frequently accompanied by dementia.  The combination affects a disproportionate number of people too young for Medicare, and, again, discharge becomes problematic.

The elderly come to the end of their road with or without dementia; their mental status has little to do with how much their families love them.  Whether beloved or not, the drama of the hospital scene transcends culture and language.

Though most alcoholics smoke, not all smokers drink.  The two most addictive drugs in our culture usually go hand in hand, and the presence of other mental or physical disease brings layer on layer of irony and problems, some of which can’t be solved. 

Bones break, most fractures don’t require hospital care, but while a person heals from a fracture they tend to get illnesses requiring hospitalization, which complicates the fracture care while the fracture care complicates their other problems.

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.