Posts Tagged ‘inpatient’

A part-timer goes part-time

January 9, 2014

We were just about to our knees

“Part-time” was only a tease

We’re doing outpatient care

And we’ve time to spare

And full-time seems like a breeze

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 position with a Community Health Center.   

On December 1, our clinic relinquished adult inpatients at both hospitals to the two hospitalist services.  We continue to take care of hospitalized children and newborns.

When I first signed on, my contract specified I would see hospital patients in the mornings and take care of outpatients in the afternoon.  Within six months our hospital practice had grown past the point where one doc could take care of the whole census, and we hired a fulltime hospitalist.

Rarely do situations stay stable, and our inpatient load expanded to the point that our full-time hospitalist needed a “hospital helper,” to see patients under the age of 18 along with one hospital.  The hospital helper would finish morning rounds, and do afternoon clinic.

We handled the daytime work without problem.  I enjoyed the physical, mental, social, intellectual, and spiritual challenge of hospital work.  The nighttime call burden became unsustainable.  Most evenings after clinic, “call” meant admitting patients at both hospitals till 11:00PM, and a minimum of 6 phone calls between midnight and 7:00 AM.  The vast majority of the phone communications involved making life-and-death decisions, and each one demanded awakening fully.  As time progressed, our patient numbers increased, and the patients we cared for grew sicker.  And my part-time position came to eat 54 hours a week, not counting time required to recover the day after call.

As our staffers drifted towards burnout, our devotion and caring for each other never faltered.  Each of us tried to make adjustments to cope with the unreasonable.  One used vacation days to not work Tuesdays, one went to part-time.  I took a cut in pay so I wouldn’t see patients the afternoon after call.  And I formulated an exit strategy.

I had tap danced on the brink of burnout before, I could sense the symptoms coming back, and I didn’t like it. The more my fatigue, the less my empathy.  One evening I recounted a conversation with a particularly difficult patient to my wife.  “You’re angry with him,” she said, “He deserves a different doctor,” and I couldn’t deny the truth.

It took a new CEO with incredible negotiating skills to recognize the problem, devise a solution, and implement it.

You can see the relief in the faces of the physicians now.  With clearer complexions reflecting better sleep, we tend to chuckle, giggle and laugh when we talk.  Most night call involves more mistake beeps than real ones.

One can easily see the toll the vigilance takes during call hours; the doc stays on edge waiting for the next interruption.  We did not anticipate the relief that would come from general stress lowering, but that relief has come to us, very real and very strong.

Our patients have lost little continuity of care, the theoretic advantage of a practice holding on to inpatient duties, because the burden demanded rotation.

For the first time since I finished undergrad, my work week comes close to 40 hours and most weeks finish on Wednesday.   I have time for both recreational reading and for writing.

I’m back from the brink of burnout.  Again.

An inpatient care program drawing to a close

November 24, 2013

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 6th 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.

The difference between a horse and a mule

August 23, 2012

It’s unnecessary to that much force

To run to the ground a great horse.

So don’t be a fool,

You can stop, like a mule

If your motives come from the source.

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.

Even doctors have to have doctors.

I confirmed my appointment with a subspecialist today at 12:45, and I turned to Bethany.  “He works through his lunch hour,” I said.  “Should I bring him a sandwich or something?”

“I don’t know,” she said, “Are you sure he doesn’t take a late lunch?”

“Yeah, his nurse said he was working through his lunch hour.”

“You can if you want.  But is he working for someone else?”

“No,” I said, “He owns his practice.”

“Well, when you were an owner, you did the same thing.”

Of course she was right.  “That’s the difference between a horse and a mule,” I said.

A horse has a passion to run, I explained, and riding a good horse hard ranks among the great experiences of life.  A mule has none of the fire of a horse, and the best gallop of the best mule deserves the word lackluster; the words plod and mule go well together.  Yet most riders can get a horse to run so far and so fast that the horse dies, hence our term, “ran it into the ground.”  An overloaded mule cannot be induced to move at all.

Give a horse morphine and the horse will run, give the horse an adequate amount of morphine and he’ll run himself to death even without a rider.

I approach analogies between humans and animals with caution.  But making any person, and particularly a doctor, their own boss looks a lot like giving morphine to a horse.  They don’t take enough vacation, they work very long, very productive hours, and they tend to burn out.

I wish going onto salary had made me more like a mule.  As it is, my drive to work destructively long hours has nothing to do with the money but with the action of the job and my commitment to my colleagues.  I do not want to give up the drama and irony of the hospital work, nor the intellectual challenge of having to rub elbows with docs who know more than I do.  Nor do I want to stop being part of the team, going the extra mile to lighten the load of the doctor who comes after me.

The problem comes not from the outpatient hours, but from the people who get desperately ill after hours and on weekends, and from our booming expansion.  My first two weekend calls last year had a total hospital census in the single digits, but our practice now averages seven hospital admissions per twenty-four hours and our hospital census has gone as high as forty-two. 

Yet this last weekend deserves a delicious rating.  I started early, finished rounds in good time, lunched and napped and supped, getting into bed before eleven each night.  I’m running on the same relaxed euphoria that I did a year ago.

The real question is how hard I’ll let myself get worked.

On finding the right quest

July 31, 2012

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.