An inpatient care program drawing to a close

As I walk down a hospital hall

I think of the burden of call

What helps me to cope

Is a heart full of hope

That this month is the end of it all.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and a trip to Mexico for our daughter’s wedding.

Our clinic’s inpatient program draws to a close in ten days.

The US remains the only industrialized country where primary care doctors attend hospitalized patients on a regular basis; for most of the world primary care ends at the hospital doors.

Community Health Centers, in particular, rarely send their docs to the hospitals.

I like making rounds, and talking to the specialists.  I have established a rapport over the years with physicians who know more than I do about their fields, and I enjoy the learning process.  On a usual basis I will leave the lunch table in the lounge a better doctor.  A tremendous amount of learning goes on in the peer-to-peer environment.   Once in a while I’m the teacher.

Today I saw 10 patients, ranging in age from 1 day to 77 years in one of the hospitals.  The problems included renal failure (both acute and chronic) abdominal aortic aneurysm, thoracic aortic aneurysm, COPD, cellulitis (face and leg), pelvic inflammatory disease, bipolar type I, alcohol abuse, tobacco abuse, hepatitis C, cirrhosis, chronic pain, narcotics abuse, amphetamine abuse, rectal bleeding, and pneumonia.  I greeted patients in Somali, English, and Spanish.   I got consultations, both curbside and formal, in cardiology, surgery, nephrology, and pulmonology.

Every patient came with a unique and fascinating back story.

I arrived at the hospital at 7:00AM and I left at noon.  Mostly I take the elevator to the 6^th floor and work my way down, but today I took the stairs up to the nursery on the second floor, and worked my way up from there.

I discharged two patients.  In an irony of specialist vs. generalist, I did a consultation on a patient with a problem outside the expertise and field of the admitting doc.

I uncovered a few surprises, mostly to do with vitamin D and underactive thyroids.

I walked the hospital corridors and dictated into my hand-held recorder suffused with an existential awareness, which I can compare to the edginess of a high school senior in late May.

However much I find meaning and pleasure in the rounds of inpatient work, the afterhours call burden has become unsustainable.  I won’t miss the phone calls ripping me from sleep through the early morning hours and recovering from a bad night on call; it now takes me three days of a zombie fog in the wake of such a night.

After December 3, we’ll take hospital call only for pediatrics and newborns.  I’ll be able to exercise and sleep on the nights when I have call.

I hope.

Discharge summaries

The patient’s in-hospital chart,

I’ll finish right now, if I’m smart

The time I can ration

To complete the dictation,

To describe the finish and start.

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.

Completion of a hospital medical record demands a discharge summary.  Nobody ever showed us what a good discharge summary looked like in med school.  We learned from examples, mostly bad.

Med student discharge summaries didn’t count.  In residency I went for thorough at the expense of brevity.  I regurgitated the history and physical, admitting lab and x-ray results, admitting diagnosis, hospital course, and discharge planning in excruciating and unnecessary detail, going through the layers of paper chart day by day. Sometimes the discharge summary went to three pages, single spaced. 

In the Indian Health Service I had to cut back on my words.  However intelligent and hardworking a transcriptionist might be, lack of training in medical terminology made for a lot of errors to correct to finish the product.  Just as well; when I took to typing out my own discharge summaries I pared down the turgid phraseology and left out a lot of irrelevant numbers.  The documents became more useful.

Medical chart completion ranked low on my priorities for most of the time I spent in private practice.  I found motivation only in the periodic letters I got from Medical Records telling me I’d be suspended from the staff if I didn’t finish my charts.

Through my career the grace period, from the day of discharge to the date of suspension, has shrunk from a year in the 70’s to six months in the 80’s, and has now remained at a well-enforced 90 days for the last 15 years. 

But the pace of medicine keeps accelerating.  We strive to follow the patient less than a week after discharge, and the follow-up doc usually didn’t see the patient in the hospital.  The discharge summary becomes less of a formality and more of a necessary and useful document.  I usually dictate the summary at the time of discharge, standing in the hallway.

My format has changed.  A line or two for the story of why the patient came to the hospital, a paragraph each for relevant past medical/personal/family/social history and abnormal physical findings.  A paragraph for lab and x-ray, followed by a paragraph for hospital course, discharge medications plans, and final diagnosis. 

Even at that, a long, a complicated hospitalization (one recently lasted 29 days)can give rise to a two-page discharge summary, but most take a page or less.

In that short space, the necessary confines for a useful document, I can give the facts but not the meaning.  I don’t get to use phrases like self-defeating behavior or inadequate reality testing or stinkin’ thinkin’ or self-imposed social isolation.  If I dictate patient refused counseling, I don’t get to go into the nitty-gritty of why.

The hardest discharge summaries end with “The patient continued to deteriorate and died on…”  Such a stock phrase gives a hollow echo of the drama and irony playing out the final act on the hospital stage, but such phrases I use on a regular basis.  And every time, I can’t help but pause.  The patient gets a moment of silence from me, whether I intend to or not. 

The transcriptionist, I am sure, hears in my voice how my world diminishes with every patient’s death.

Weekend rounds in vignettes

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.

On finding the right quest

Of this I have been impressed

Some people ended up stressed

Life might be breeze

They might do what they please

But they need to follow a quest

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 work late Mondays.  I start at the hospital between 6:00AM and 7:00AM, leaving in time so that I can start clinic at noon.  I may or may not get a breather to eat, and I care for patients till 8:00 PM. 

Tonight I got a break when my last patient of the evening, who had never been seen at the clinic before, failed to show for the appointment.  I’d guess that a substance abuse disorder lies at the base of the person’s problems, but, having never met them, I can’t say for sure.  I used the extra time to catch up on documentation, but left before 8:00PM to go to the gym. 

Yet Mondays do not rank as my usual heavy day; that distinction belongs to Tuesdays, when I usually take call.  I generally roll up to the clinic before 7:00AM, and take advantage of the quiet to sort through arriving lab results and other paperwork.  Patients start at 8:00AM, scheduled till noon, and the afternoon session starts at 1:00PM and runs till 4:30.  I continue to document at my desk till the ER calls me for an admission.  On occasion I’ve left my desk at 6:00PM when my efficiency fails.

Today I found a census of twenty-two waiting for me at the hospital.  I rounded on eleven of them, discharged four, and then I headed to the clinic.  I turned the others over to our full-time hospitalist.

In twenty-first century Iowa, most people need to lose weight, but our patient population has such a grand mix of pathology that today I took care of two who needed to gain.  

To put on weight I advise three scoops of expensive ice cream at bedtime.  (If you need to lose weight, you’re never going to do it if your bedtime snack continues.)  All the folks I take care who have lost too much weight have an identifiable illness, though sometimes it doesn’t account for all the person’s symptoms. 

I sat and philosophized with a young person I had coaxed back up across the 100-pound line.  I had correctly identified the pathology and, working with the patient, had come a long way towards correcting it.  Yet a problem in the grander scheme of things remained. 

Sometimes I talk to high school health classes, I told the patient, and if I walk into a classroom of 35 students I can usually be sure at least one has set him or herself on a quest for wisdom.  Others are born musicians or artists, photographers or historians.  Whatever that person might do for a living, if they can’t also follow their quest, something inside of them dies.

The patient nodded and said, “That’s my problem.  I haven’t found my quest.”

I said, “But not everyone has one or needs one.”

 And in fact, most people don’t.

When is a trip home like a spider? When it has eight legs.

A limerick isn’t a poem

A blog sure isn’t a tome

     This thing they call jet lag

     Comes out to big drag

But happiness is being back home.

Synopsis:  I’m a family practitioner from Sioux City, Iowa. I took a sabbatical to dance back from the brink of burnout.  While my one-year non-compete clause ticked away, I worked in Alaska, Iowa, Nebraska, and Alaska.  I had a lot of adventures working in out-of-the-way places.  Now I’m back home, getting ready to start my new job.

When is a trip home like a spider?  When it has eight legs. 

Our trip home lasted thirty-eight hours and left us with the worst jet lag we’ve ever had.  We slept badly even before boarding the plane in Dunedin.  From Dunedin to Christchurch to Wellington to Auckland (thirteen hours) we might have napped on the plane, but we didn’t get restorative sleep. 

Turbulence, related to the recent Chilean volcanoes, dominated the twelve hours spent flying to Los Angeles.  I ignored the bucking airplane and watched three movies, and didn’t sleep. 

By the time we deplaned in Phoenix’s late afternoon the temperature exceeded anything we’d experienced in New Zealand. 

Omaha at midnight had darkness and thick, sweet summer air.  Long detours necessitated by the Missouri River flooding added an extra forty-five minutes to the drive home.  By the time we actually walked into the house the clock came close to 3:00 AM.  Our trip had lasted thirty-eight hours, if you don’t count the travel from Bluff to Dunedin. 

Jet lag hit us hard in LA and didn’t get better as we progressed.  Both aware that neither of us could process information well, we showed immense patience with each other; I doubt either of us could have negotiated the trip home alone.

We suffer not just from the time difference but also from the abrupt change of season.  We departed for New Zealand near the equinox, when day and night all over the planet approached twelve hours, but we returned home just before the solstice.  Dunedin’s shortest day would coincide with Sioux City’s shortest night a mere eight days after we landed.

Our body clocks have been thrown into chaos.  I have been on the ground for three days and only now am I starting to write again.  I awaken at about 4:00AM and crash hard at one in the afternoon.

Of course I went to my new work place less than twenty-four hours after I arrived; I needed to discuss my upcoming schedule.

Unlike a lot of the family practitioners these days I enjoy hospital work, rubbing elbows with the specialists and providing continuity of care.  My new routine will start with hospital rounds for the group Monday, Tuesday, and Wednesday.  If things go according to plan, after lunch those days I’ll do clinic, and I’ll have an evening clinic on Mondays.   Those twenty-eight hours, combined with my share of a one-in-eight call rotation, add up to 45.7 average hours per week, which, for a doctor, means part-time work.