Emergencies 

Sunset reflected in a road puddle
“I want a wart removed this Friday”

“The doctor does not have any openings for a procedure this week. We are short staffed and she is completely booked. We can get you in on Monday if you like.”

“I am going on vacation next week. The doctor always accomodates me! You tell her I want to have this removed on Friday.”

I do try hard to get people in when they need it. But sometimes…

Honestly, it has been a rough week. 

With one of my partners out, our nurse practitioner out, AND it being the week before school starts back for many kids in the area… the clinic has been crazy. Finding time to blog/breathe/pee has been hard to come by.

“Fine! You tell her I am finding another doctor.”

It is like this every year. 

Next week it will be a ghost town around here but for now those emergency wart removals are killing us. 

A Mistaken Identity 

Hudson Bay clouds

My heart sank into the floor.

“You did what?”

“I gave the wrong immunization! I didn’t look close enough at the orders.”

The baby ended up getting a double dose of one of the routine childhood vaccinations because my medical assistant gave the wrong combination vaccination and overlapped. It was not a terrible error, as far as medical errors go, and would not cause harm but try to convince a parent who has gone through multiple miscarriages and IVF to get this one beautiful baby boy. It was not a phone call I looked forward to making.

I could ignore that it happened, sweep it under the rug so to speak. Make it disappear. They would never know….

Still it had to be done. They had the right to know. So I did it. I called and explained and reassured. They seemed to take it very well at the time, or so it seemed.

I see FOUR generations of this family. 

Four.

Or rather, saw. 

They left my practice. 

To be honest, if it were my own kid I would have probably not been nearly so nice about it and I would have also taken my kids elsewhere. I am not upset at this family at all. It hurts but I totally get it. 

Trust is gone.

This was the first time an incorrect pediatric vaccination was given by a staff member to my knowledge in my practice. Fourteen years. That means nothing when it’s your kid. One mistake. Made by one of the best medical assistants we have, the absolute last person I would have expected to make an error. She will carry that one around for a very long time. 

So will I.

We can learn from every mistake, can’t we? 

If I told you I had never made a bad call or made a mistake myself I would be lying to you. There is no perfect doctor. Sometimes we lie to ourselves. Sometimes we lie to other people. That is how we keep going each day. We are not perfect. I know each and every mistake I have made over the years and they play in my mind over and over again, their faces pop out at me usually when I am already upset about something else that is unrelated. 

See? You suck, you suck, you suck! 

Why does our brain do that to us? Kick us when we are down?

Sometimes it is hard in the aftermath of a “mistake” to clear the mind and keep focused. There are other patients to see, my family to take care of. Still, I also need time to grieve and process. To forgive myself. To forgive others. I need people around me, my family, to let me do that without trying to “fix” me. Eventually my mind will settle down and move on.

Because life goes on.

It always does.

‘Tis the Season

Dried flower

There was a time I believed that the longer I was practicing medicine the easier the dying would get. Practice or callous formation, call it what you will. I just thought it would be easier.

That is not the case, though. 

These long standing relationships, the people I see for years and years, are the hardest to part with even when you are expecting it. It still hurts. And with each passing it brings me closer and closer to my own end.

This is the dying season, it seems, those couple of months after the holidays when everyone who was holding on is now ready to let go. 

Everyone but me. 

Not yet, anyway…

Ornamental

Epstein Barr Christmas tree ornament.
Growing up we had a plastic tree that looked so obviously fake that it was mortifying. So much so, I never invited friends over for the month of December lest word of this “tree” got out to the general public. Hell, I didn’t invite anyone over for January, either, because that sucker was still up into February some years. I swore back then that I would only have a real tree when I was grown up and on my own and I would take it down the day after Christmas.

My first year of medical school, as I began wracking up the close to $100,000 debt for my education, I decided it was time for my first tree. So I went to the local home and garden store, in this case, Home Depot, and found that while I had enough money to buy a tree stand I did not have the money to purchase the actual tree. 

This was a problem.

Instead, I purchased a scrawny, pathetic little thing that measured maybe a foot and a half high for $10. It was a little seedling in a red plastic wrapped pot that was sprayed with glitter on the branch tips. I consoled myself by saying that I could plant it afterward and would not have to live with a murdered tree on my conscience. It was so flimsy, though, that any ornament, even those hollow blown glass balls, sent it drooping, bending over to kiss the tabletop. 

Ultimately, that tree never did get planted. I lived in an apartment after all. There was no place to plant it. While I could have taken it to my parents home and planted it in their yard, that would have required explaining the reality of my first tree to them after my many years of boastful scoffing. So far as they knew, my tree was a magnificent specimen of Yuletide cheer and I was going to keep it that way.

Pride. 

Pride made me kill that tree and after a few months, when it had finally turned all brown and dessicated, I threw it into the back dumpster to hide the evidence.

Incidentally, my parents still use the hideous plastic monstrosity of my childhood. It gets barer every year as bits and pieces fall off but it is still recognizable as a tree. That thing may just outlast us all.

(The photo above is one of the ornaments on my tree. Care to hazard a guess as to what exactly it is? Hint: It is an infectious partical and it cracks me up every time I look at it!)

The Lost Dollars

img_2419

So there is this thing in the US that you may not have heard about. ACO’s, Accountable Care Organizations, are groups of physicians that have “joined together to provide high quality care” for Medicare patients. So says the CMS (Medicare) website.

What does this mean for patients?

Hell if I know. I don’t practice medicine any differently than I always have except that I find myself spending more and more of my time clicking the requisite buttons in the EHR (electronic health record) so patients get less of me. Quality care is quality care and should be given across the board to all patients no matter what bonus structure happens to be in place. I do have suits that come out and flash PowerPoint slides at me that tell how many of my patients ended up in the ER over the past quarter but I don’t pay attention. Frankly, I should not be making a decision whether or not a patient needs to go the ER based on what my “numbers” may or may not look like. 

What does that mean for physicians?

Supposedly, I get money every year that I can demonstrate that I provided savings to Medicare. If Medicare does not spend as much money but patients still get their colonoscopies and whatever else done (I have no idea how that is supposed to work), then I get a share of the “savings.”

How big is that check?

It is not like winning the lottery, that is for sure. I resent the insinuation that I need to be paid extra to do the right thing, but that is beside the point.

The healthcare corporation I work for requires me to complete some…. tasks… before I get this check.

For instance, I have to attend quarterly regional meetings and log onto two separate websites each and every month. To be honest, none of the physicians I know look at anything on those websites. They log on and log off to get the credit. (Of note, I have asked why it has to be two websites. Why can’t it just be one? No one gives me an answer.)

All of this, if it actually improved patient care, would be fine. But it doesn’t. Not one bit. It turns physicians into cute puppies doing silly tricks for their next treat and I refuse to participate. 

By not participating, however, the corporation gets to keep that check. I might not care about that if I knew it was going to go to helping indigent patients get access to care or some other noble cause but I don’t have the foggiest idea what they plan to do with it…

Personally, I think it should go back to Medicare.

Advisory

Taylor, a high school student thinking about medical school, asked some questions on my It’s All An Act post about six weeks ago. I had been saving these because I wanted to think about them for a bit.

How did you choose your specialty?

I chose family medicine so that I would not get bored. I get to see patients diaper to diaper and everything in between. In truth, I had it narrowed down to surgery, psychiatry, and family medicine. Surgery was a lifestyle I was not sure I could cope with in the end, despite how much I loved it. Psychiatry… that deserves its own post, but after doing a few extra rotations I was disheartened by what I saw. That left family medicine. I still think I picked the right one, despite my grumblings about the various frustrations of primary care.

If you had the chance to change anything about your career, what would it be?

The EHR. I will rant more about this later. I don’t understand why we cannot have a simple, straightforward system that is intuitive. This is 2016, for crying out loud. We put man on the moon decades ago! This is not rocket science.

Is medicine worth the 20 years of education/sacrifice in your twenties?

Yes. I have a placard that hangs over the door in my office, so I can see it every time I step out to see a patient. “One shoe can change your life. -Cinderella” That may seem cheesy and trite but I have done more, see more, accomplished more than I ever thought possible. Medicine is my shoe. It is an honor and privilege to get to practice medicine every day.

Do you have any advice for aspiring physicians?

There is no substitute for hard work. This sounds simplistic but there it is. You have to be smart, sure, but without hard work, smart is meaningless. 

My First

Buckingham Fountain in Chicago

I don’t remember my first patient. Not from medical school or residency or even private practice. It struck me when Linda Bethea of Nutsrok asked the question, that I have no idea who those people were at those milestones in my life.

What do I remember, then?

I remember being terrified. 

Was I going to make a fool out of myself? Would I misdiagnose something? What if they didn’t like me? 

There are many patients that I do remember over the years. They all taught me something. Even if I made a mistake. Even if they didn’t like me. Even if I didn’t like them. Even if I don’t remember their names or their faces now. Who I am today, as a physician and a person, is largely due to an accumulation of experience from all of them. 

So maybe I don’t remember my first. Or even my second. But maybe that doesn’t matter so much. 

I bet I WILL remember my last…

(Go check out Linda’s new book!)

Phlegmon

Infected tissue
Perforated viscera
Appendectomy

Medicine is rife with fabulous words, like bezoar and borborygmi, and haiku is particularly well suited to them. Phlegmon is one of my favorites…. you don’t even have to know what that word actually means to know it is something bad, right? The very sound of it gives me the willies. In case you are interested, a phlegmon is inflammation and infiltration of subcutaneous tissues due to infection. 

(Oh! And please forgive the accidental premature posting of Mediocre Medical Poetry last night!)

Flawed 

There are a surprising number of physicians who blog. I loved this post from Deconstructing Doctor about how it feels to potentially miss something, how it can eat you up, how isolating the medical profession can be. Check her out!

deconstructingdoctor.com

broken-saint-1422381-639x573I don’t always do the right thing.  I don’t always figure it out.  That’s the worst part of this job.  The not being perfect part because not being perfect means I’m flawed and flawed people make mistakes and my mistakes can hurt people.

One time I almost missed a lung cancer.  Oh God, the gut-wrenching weekend that I spent after that one.  I must have lost 5 pounds just from the nausea that I felt.  How could I eat?  How could I breathe?  My mind ground the details of the entire chart into a fine powder and then I sifted through that.  Trying to account for every dust particle.  How could I have failed so miserably?  I could have just died.  Truly.  What a miserable wretch I was.

The crazy part is it couldn’t have been helped.

She had lung cancer a decade before.  It came back.  My angst came…

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Am I Dreaming Yet?

dinosaur hanging from the ceiling of the Field Museum in Chicago

It was 4PM. I snapped awake at the desk, looking around quickly to see if anyone had noticed my moment of weakness. 

No one was watching.

Relieved, I continued to dictate the patient’s discharge summary. As words tumbled from my lips, I realized they were not making any kind of sense. I stopped the recording and replayed what I had just said.

A bunch of gibberish.

I tried again, rewinding back further. Still gibberish. 

Fully awake now, heart racing, I trashed the whole dictation and started over again, jotting down a quick outline so my brain would not get lost.

My whole body ached from the fatigue. All I wanted was a bed. Nice cool sheets. A fluffy pillow. Maybe a soft blanket or two. Darkness would be nice but was not critical.

Then my pen started to laugh at me.

Wait. 

Was that a dream or a hallucination? After 38 hours of awake, I was no longer sure…

It was the very first hospital shift of my intern year of residency. I had never been up that long at one stretch before.

When people talk about how hard residency was, this is what I remember… the bone aching fatigue. When I was moving, things were better, so when I was on the hospital service I got into the habit of dictating and writing orders while standing up instead of sitting down. I think I got used to the sleep deprivation, if you can imagine. 

Resident work hour restrictions went into effect my last year of residency. Rather than coasting to graduation, letting everyone else cover call, I found myself covering intern and second year primary calls overnight at the hospital, filling in their gaps. My class worked much harder than anyone before or after us. We were caught in the middle.

Interestingly, while everyone believes work hour restrictions save lives, what they don’t realize is that it has increased medical errors from more frequent hand offs. When you go off duty, you have to check out your patients to the next physician. It is not possible to discuss in detail every event of the preceding shift, so you give a short summary. It is thought that the more frequent hand offs, increasing those lost details, has caused an increase in medical errors that cancels out the fewer errors from sleep deprivation.

So in the end, it’s a wash. 

Seriously.

Personally, I think the longer hours made me tougher, taught me that I could do and survive much more than I ever thought possible. It reinforced my work ethic. It exposed me to a lot more medical knowledge than I would have gotten otherwise. It helped shape me into the person I am now.

Does that mean we should go back to insane work hours? 

Not necessarily. 

Sleep deprivation clearly does increase errors, but that isn’t the only source of medical errors. We need to drill down on those. We need to figure out better ways to do patient hand offs. We may need to add a year to family practice residency in order to get the proper exposure, to ensure we are graduating solid physicians. 

I love that people are looking at these things more closely now, identifying where errors are coming from, but dang if we don’t move painfully slow on this front. Work hour changes in the U.S. went into effect over a decade ago…. Seems like we should have a better handle on this by now.