Posts Tagged ‘weekend call’

Iowa house calls, back to Pennsylvania

August 7, 2015

For a house call I went to a store
Then expected one or two more
To come to my house
So I said to my spouse,
They’ll come in through the front door.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

While home in Iowa last week I made a couple of house calls.

One patient owns a business I frequent, and had called me when we were both on the way back to Iowa. Our professional relationship dates back well into the last century. We have watched each other progress professionally and socially. He gave me the go ahead to write the entire visit in this venue as a record, but, for the same reason I conducted the interview on the deserted freight dock and the exam in the store’s quietest corner, I didn’t. At the end, he personally helped me with my selections and would not accept money for the transaction; nor would I accept payment from him.

Another friend has had a problem building for months; we agreed on the next step: the specialist.

The garden has come in, and Bethany and I snacked on the first of the tomatoes, cucumbers, and green chiles; We invited company for supper on Friday. For a side dish, I cut sweet corn from the cob, added red onion, roasted green chiles, lime juice, and olive oil.

I took call for my Community Health Center the weekend. One patient discharged from peds on Saturday and one admitted on Sunday,far cry from a census demanding two docs to round both mornings, with one up all night to take admits and calls.

Tuesday found us back in Pennsylvania, at an Urgent Care, working 12 hour days, but this time we can walk from the hotel to the clinic. I like the medical record system. I can whiz through documentation for respiratory problems, but skin and musculo-skeletal problems need more narrative because no two are the same. A disproportionate number of patients come in with poison ivy.

Urgent Care, by definition, doesn’t include ailments that need follow-up or CT scans. I sent a number of patients each with suspected heart attacks, blood clots, or kidney stones to the local ER. People with bipolar disease tend to have very real, severe physical problems. I can treat those injuries, but getting at the root cause falls outside my scope of practice.

To those patients who come in, for example, with weight loss (now into the double digits working for this client) I say, “This is not normal, but there is a limit to what can be known an hour, and there is a limit to the lab we can run in Urgent Care. You need a primary care provider, and here is a list of labs that he or she might run.”

Nor can I effectively treat rheumatologic problems, but rheumatologic patients come to see me nonetheless. From time to time I run into people on Enbrel, and then we generally have a happy support group meeting. We talk about how the drug changed our lives; how, coming out of the pain we could engage emotionally with our families; and about how, outside the pain relief, we just feel better; (I feel better now than I did at age 18).

If I talk to a back pain patient on opiates, I tell them how the medication inhibits their own ability to make endorphins and perceive endorphins. Some express shock and amazement, and some just want me to prescribe the Norco, because “it’s the only thing that works.”

Advertisements

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.

Sleepless doctors losing caring

May 7, 2013

We deal with death and with pain

The job brings a whole lot of strain

The hours on call

Are the worst of it all

When your sleep goes right down the drain

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.

Sunday afternoon in the doctors’ lounge the faces show the strain.  We have worked too many hours too intensely.  The energy and the intelligence helps but 48 hours into the weekend call the pulmonolgist, the nephrologist, the hospitalist, the cardiologist and the family practitioners have all done too many admits in the context of not enough restful sleep.

As a med student and a resident I had times on call when I made the mistake of letting myself go all the way to sleep, and then I aroused only with difficulty.  Now amusing stories at the time carried frightful embarrassment.  Most docs had similar experiences, and we learned to doze rather than sleep fully.  I’ve asked other physicians, and about 15% say they can sleep well if they’re on call.  I fall into the other group. 

The muscles in my upper back and the base of my neck grow tender knots and then cramp up. 

With the geographic layout of our town’s two hospitals, walking from car to patient to car, a round trip of hospital-patient-hospital-patient comes to a little over a mile, and with admissions piling up at the average rate of 4 to a shift, physical fatigue adds itself to the list of emotional and intellectual weariness.

Even the brilliant, overachieving docs from other countries who work insane hours without complaining (the way I did as a resident) look tired.  While no one wants to be seen as a whiner, we commiserate and we wonder why this weekend, of all weekends, should be so hard.

My near participation in the pity party ends when my beeper for the other hospital goes off.

I can tell from his use of profanity that the ER specialist has passed his emotional elastic limit.  All his rant about the alcoholic’s manipulative behavior rests solidly on truth, and I recognize in my heart my own impatience with the self-defeating behaviors that brought the person in.  But the doc on the other end of the line goes on for minutes, communicating little about the patient’s medical condition and much about his own anger. 

Across town the patient’s blood alcohol level runs 224.  From experience I know that the interview process will yield little useful information.  Drunk patients want to appear clever and they want to talk and they have problems focusing, but as a physician I just want to collect the information and go home.  I don’t try very hard when it comes to my 140 question Review of Systems, where I ask the patient about every symptom possible.  I break off questioning at the first sarcastic remark, and I don’t try to fight the scrunched-up eyelids to examine the pupils.  My dictation uses the sentence, “could not be obtained because of patient intoxication” a lot.

Overworked docs with inadequate sleep may or may not provide the same quality of care as normally, but they definitely lose out on caring.