Mission creep: a census grows and genomics comes now comes retail

Does a thousand seem likes it’s cheap?

Beware the assumptions you keep.

Don’t think that it’s strange,

There will always be change,

And ever the mission will creep. 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

Last night I took the handoff for a hospital census of 4, a record low since I started with this clinic.  Even though I arrived for rounds before 7:00AM, that number had grown by 3.  I whizzed through two admissions, three patients with kidney failure, one each with alcohol withdrawal and complex pneumonia, five diabetics, a newborn, and two coronary patients.  (Do the math, you’ll figure out that a patient rarely enters the hospital with one problem.)

The longer a person lives, the richer their life story; and in the course of half an hour I had the treat of listening to a wonderful family history unfolding over the course of three generations.  I left them hope that the specialist would be able to cure the problem. 

But I squandered 15 minutes trying to educate a nurse, who overhearing me speak Spanish, made disparaging remarks about immigrants. 

Still I finished at the one hospital before ten.  At the second hospital, still in the throes of transition from paper charts to a new Electronic Medical Record (EMR) system, I only had to round on the pediatric floor, and I held onto hope of getting to the office early. 

I discovered an EMR quirk: one now needs 9 keystrokes, not 1, to edit a dictation.

I got to the office early, but not nearly as early as I’d hoped.

After half an hour of buffing documentation and messages, I attended what had been billed as a provider meeting.

The man who brought the lunch didn’t pitch a drug but a lab test.  Using material on a cotton swab from the inside of the mouth, for a mere thousand dollars, his company can provide us with genomic information about how fast or slow a person might metabolize a range of medications. 

For example, a single standard 30mg dose of codeine provides good pain relief for 80% of the population.   But 20% of population lacks the enzyme to convert codeine to morphine; for those people, codeine might suppress a cough but won’t relieve pain.  The super enzyme found in 1 in 3 Somalis converts 100% of the codeine to morphine on the first pass through the liver, enough to kill half of those who try it.    

Our clinic prescribes almost no codeine.  For whom will the test bring a thousand dollars with of benefit when it comes to choosing an antidepressant, antipsychotic, or ADHD medication?  We requested more information.

I didn’t ask the larger question: how long will it be till an entire genomic sequencing becomes available for that price? 

Mission creep remains a permanent fixture on the constantly shifting medical landscape.  Whether a doctor deals with a growing census, or a company sells technologic improvements, we all know that the world, at the end of the day, will not be the world we had at the beginning.

 

 

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.

Serving notice

Resignation letter

17 February 2010

 

I won’t whine about working so late

For I know that the stress will abate.

            Things will get better

            For I turned in the letter,

May 24^th is the date

Early in the graying morning I retrace my old steps to Mercy Medical Center to visit the newborn and dismiss her.  When I arrive the doctor’s parking lot is still empty, the lounge is quiet.  The nurses, however, are at shift change and the manic spirit of those about to go home mixes with the optimism of those coming on.  I look north down the main corridor and I point out the beautiful golden morning light staining the walls at the end of the hallway, rays coming horizontally, flush with the wall. 

OB and nursery are on the top floor of the old part of the hospital.  Twenty years ago I came here a good bit, now it’s rare.  I’m trying to get out of the baby delivery business.

I won’t miss Mercy.  A couple of years ago they installed a highly dysfunctional medical records system and a group of cheerleaders to deny that there was anything wrong with it. I’ve done my best to stay out of there ever since. 

Rounding at two hospitals is fabulously inefficient, seeing two patients generally took an hour and a half with more time spent driving than spent face to face with patients.  Our group split the work of the two hospitals about six years ago, so that one doctor would round at one hospital instead of six going to both hospitals, and then we rotated weeks, coming into the office an hour later when we had hospital duties.  Then when both hospitals installed hospitalist programs we could give over almost all of our patients to docs who do nothing else.  We still see our own newborns, they’re the most fun thing in a hospital.

I go down the back stairs, an architectural remnant of the times when people used the stairs a lot, and I read the funnies in the doctors’ lounge while I eat an orange.

The sun is bright when I leave the hospital, a relief to the eyes.

First thing at the office I pick up the dictating machine.  I went through one about every seven years, this one has lasted longer because we don’t dictate with the new system.  I dictate my notice.

It’s not easy to do.  I have to look at a calendar to find the Friday before Memorial Day weekend.  It will be the day before my wife’s birthday.

I carry the recorder back to the transcriptionist.  She’s been working with me for 18 years.  Back in the day, one afternoon my nurse, the transcriptionist, and I went to lunch together, and I found out I could dictate in macros, which saved me about 20 minutes a day.  I still didn’t get out earlier. 

I warn her to get out her Kleenex. 

An hour and a half later she comes in with tear-stained cheeks and hands me four copies, three of which I sign and one of which I casually stash in my desk drawer, a single sheet bringing an end to 22 years of service, almost a quarter century of watching the drama and irony of the human condition in one place.

The day goes long, and I go to the gym when most people go to supper.  I have just worked up a really good sweat when my beeper buzzes on my hip.  Our Urgent Care needs me; they’re backed up.  The doctor on call for the group serves as back up when the regular staffer at Urgent Care is overwhelmed.

For an hour and a half I explain to concerned parents why the child doesn’t need antibiotics, to another patient why he does, and to one other why he really, really needs a CAT scan tonight. 

I get home at 9:30, and I know I should go right to bed, but I start with a limerick and I can’t stop.