Posts Tagged ‘vigilance’

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.

Call without flak jacket

December 22, 2013

For call, the way to prepare

Is to grit your teeth if you dare.

But this busy season

The load’s come within reason

And doesn’t hold much of a scare.

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 a position with a Community Health Center which dropped from 54 hours a week to part-time on December 1.  I’ve also 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.

It’s Sunday evening and I have weekend call but the meaning of that phrase has changed substantially. Joyously and radically.

Our practice gave our adult inpatient work to both hospitalist groups.  But internists only staff those, and neither will care for patients under the age of 18.  Thus we still attend pediatric and newborn patients.

I rounded on and discharged a young teenager at one hospital and two newborns at the other yesterday.  Today I sent those two babies home and admitted another newborn.

During medical school, standard practice demanded keeping newborns in the hospital for 5 days following normal delivery and a week following Caesarean section; by the end of residency the stays had dropped to 3 and  5 days, respectively.  Down to 2 and 3 days currently, we don’t see nearly as many septic babies as we used to when we kept the children longer in the germ-laden hospital.

When I go to the hospital and I print out the census for my group, I see names of patients admitted from our practice but on whom I don’t have to round.  One hospital had 5 names and the other had 4 yesterday and today the total came to 12, when a month ago our minimum total came to 20 and frequently ran over 30.

I have to ask myself if our respectful, expert care had anything to do with the fact that he patients kept getting so sick.  Certainly I find it believable that the drinkers would fail to learn if our well-oiled alcohol withdrawal machinery did such a great job of keeping them comfortable while they sobered up.  After all, people will jump more if you keep setting up the safety net.

But I also have to ask if our sicker patients have switched to doctors offering better continuity of care.

I slept well last night; I received no calls in the critical hours between midnight and 6:00AM.  I still got up early, had a good breakfast and went to work.  But afterwards I could go to the gym, go to brunch, take a nap, do some reading, and take in a movie.

And I could do it all without vigilance ruining the experience.

 

We used to talk about the emotional preparation for taking weekend call as “getting your flak jacket on.”  That 72 hours could be physically and emotionally exhausting, but we figured if we could make it to Sunday at noon we could handle any evil that would last less than 18 hours.I look forward to getting back to the office tomorrow.

I’m really enjoying my job now; easier without a flak jacket.

Two beepers, three phones: first night on call in Amberley

May 12, 2011

These days, the bag isn’t black,

Not one, they are four, each a pack.

      You can’t carry them far

     Unless you’ve a car

And for beepers there’s never a lack 

Synopsis: I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance from the brink of burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  Right now I’m on assignment in Waikari, a rural area in New Zealand’s North Island, an hour outside of Christchurch.

I took my first night on call. As I left the clinic in Waikari the nurse handed me four backpacks of medical equipment: one each with oxygen, resuscitation equipment, resuscitation medications, and immobilization devices like cervical collars.
My father, a physician, carried a black bag everywhere, even on vacation, and we, the children, couldn’t understand why he would do such a thing. I understand why now, and with greater understanding comes an adult’s disagreement.  A vacation needs to be a vacation, a time to rest and let go of vigilance.

An article 105 years ago in the Journal of the American Medical Association detailed what a doctor should carry so that lives could be saved outside of hospital.

The black bag has morphed into the 21st century in New Zealand.  The internal combustion engine assures the doctor that a hundred pounds of gear stays available. What would have passed for dead on the spot a hundred years ago has become salvageable.
In the US, doctors don’t get on-site trauma training. Few would go to the scene of an accident or tragedy.  Almost none make house calls, and the black bag remains a relic of the past.

Here, an on call doctor might respond to the site of a cardiac arrest or massive trauma car collision.

I made a house call in New Zealand for a post-op Maori patient.  Manicured grounds surrounded a well-maintained home down a long driveway.  (Most Kiwis take better care of their yards most Americans, and the homes, for the most part, are neater.)  I brought a stethoscope, but all I needed was good clinical judgement and compassion.

I arrived home today with two beepers clipped to my belt, one for each geographic district that I covered, and the clinic cell phone in addition to my NZ cell phone (still undependable) along with my American Droid. 

I haven’t carried a beeper for a year.  In Alaska the hospital provided a wonderfully reliable cell phone; in Keosauqua my cell phone coupled with my apartment land line served well.  With no call in Grand Island, I didn’t need any sort of after-hours communication. 

Yet I clipped the two hip-sucking parasites on my belt, and, as if they had never left, they felt right at home.  I shuddered.

With my five pieces of electronics and Bethany’s two, we went out to supper, and just as we walked up to the restaurant, my clinic cell phone rang.

I gave instruction about stopping bleeding from a cut that didn’t require stitches. 

I have discovered that the secret for sleeping well when on call consists of convincing yourself you’re not on call.  I looked at my quintuple-redundancy electronics and lied to myself, but I still had a faint niggle at the back of my mind.  Self-deception prevailed for six hours of sound sleep but not for all eight.  I received no calls.

I gave over the beepers in the morning, and as soon as I got to the clinic I gave up the extra cell phone.

Valuable lessons learned from an unreliable cell phone

April 17, 2011

Whether tool or weapon or crutch

For patients and family and such

     It’s not that I’d shirk,

     But if my phone doesn’t work

I don’t worry about being in touch.

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. 

In residency, a mentor who rightfully commanded a great deal of respect talked about the responsibility of being on call.  One evening early in his career he’d had a glass of wine with dinner, and when duty brought him into the hospital for an after-hours call, the patient smelled alcohol on his breath and commented on it.  Subsequently, that doctor would never drink in town.

One evening, during those days, I came back to my apartment exhausted after a hard night of call followed by a long day of work, and fell into an iron-clad sleep.  Two hours later a patient’s relative phoned.  I tried to talk intelligently but it took me a good five minutes and a review of everyone on my census before I had fully awakened.  I tell the story sometimes because it gets laughs, but I can still remember the active struggle for consciousness, the feeling of mental molasses behind my eyes.

Eight months later, while on OB call, after I had given myself whole-heartedly to sleep in the residents’ call room, the phone rang at 2:30AM.  I kept falling asleep trying to get out of bed, tie my shoes, and get out the door.

A few more embarrassing incidents like those taught me how to not fall completely asleep.  I think most doctors have similar experiences during their training; for one reason or another, most of us cannot sleep well when we have call.

I knew a doctor who slept as well on call as off; he said he just told himself he wasn’t on call right before he went to sleep.

Another physician of my acquaintance avoided accessibility.  To the consternation of his partners, he refused to get a cell phone.  His beeper’s notorious unreliability came from failure to charge and failure to carry.  In the last year, I’ve come to understand that his cheerful good humor and the depth of his emotional resilience stemmed from his ability to get restorative sleep on call and off, and his capacity to relax and recharge when not working.  I don’t think he’s capable of burn-out. 

Three companies provide cell phone service in New Zealand.  My agency issued me a cell phone when I arrived; and, whether from hardware, software, or service issues, it didn’t reliably receive calls.  Frustrated at first, I learned how to not worry if I went out without it.  I have since become accustomed to not having a piece of my mind devoted to vigilance.  Though the agency replaced that phone with one from a different company, I sleep as if no one’s life depends on me awakening promptly.  If I’m on call, I’m on call, and I stay at the clinic.  When I’m not on call, we walk away from home and I don’t bring my phone.  We stroll down to the beach and I don’t run up out of the water to check my beeper. 

Yes, I work 40 or 50 hours a week.  I still feel like I’m on vacation.

Firefighters get it, so do daughters

May 3, 2010

I advise, I am not commanding.

In a profession that awfully demanding.

     It has been my fate

     To have patients so great

They show me true understanding.

A firefighter came in today.  He gave me permission to write about our conversation.

He could retire in two years at half-pay if he wanted to. I made the observation that the day he went to work after he could have retired, he would only be working for half-pay.  He told me about the benefits of continuing to work, all of them true and many with a cash value.  An intelligent man, he knows how to sit down and figure out the costs and benefits of different choices.  He does his homework.

He also understands, better than most outside the medical profession, the burden of vigilance and long hours.  During his fifty-two hour work week he can be called literally at any second to perform life and death work.  His job, absolutely vital to society, robs his sleep of rest. 

He recognizes the desirability of slowing down and the dangers of stopping. 

He said he’ll miss me as his doctor, after all, he’s been my patient for almost 23 years, but he understands my decision.

He truly does. 

I asked another patient permission to put her observations in my blog, and she said yes.

“You have to do this,” she said, “And you have to do it before you burn out.  I know.  My father was a doctor and he burned out.  He had a heart attack at 62 and he died.  Take some time and enjoy life.  I’ve appreciated you as a doctor, I’ve always felt you really listen to me.  I’m going to miss you in the year you’re gone and I’m probably going to follow you when you come back to town.”

I have patients who really understand me, who really get it.

Contrast is the essence of meaning, I also have patients who don’t.

Two of today’s patients have their respective dominant thumbs firmly on the self destruct button.  They come from vastly different backgrounds, but they have come to the final common pathway to finality.  They are among the many alcoholic diabetics with high blood pressure and bad cholesterol who do not get it.  They may never get it. 

I was able to say, “You’re an alcoholic, and it’s going to kill you,” without burning any bridges.

It took me years to perfect that skill set.

I’m not done with OB yet!

February 19, 2010

FEb 19 2010
 
The morning is off to a bad start.
In the wee hours, I received a call about a patient of mine going into labor.  I commented to the nurse that a patient delivering on her due date was bound to happen sooner or later(it would have only been the third time in 31 years).  I tossed and turned till about 530, when I called to find out how the patient was doing, only to find out my partner was in the process of attending the delivery.
In a multisystem series of errors, it seems a nurse assumed I had stopped OB a few months ahead of my official stop date and called my partner.  Yes, there’s more to it than that but the explanations I get from Labor and Delivery have certain logical flaws.
I get apologies but no real indication that things are going to change.
I have had all the disadvantages of doing OB (the vigilance, the constant presence of the beeper, the sleeplesss night) and none of the advantages of doing the delivery (the joy and the continuity of care, the euphoria of being there when new hope and light come into the world).  Sort of having a hangover without getting drunk.
Even though I’ve only three months left in this position, I will be addressing the problems at multi levels today.