Rural Doctoring

The Weekly Wrap: May 24-30, 2008

Here's my weekly summary of some blog posts that got me thinking:

An Open Letter to the Woman at the Supermarket

Dear Neighbor/Patient,

It was very kind of you to inquire after the state of my garden when we bumped into each other at Safeway this morning.  We haven't seen much of each other lately and I was pleased to hear your early peas are already flowering.  We waved good-bye to each other and went about our business.  Or so I thought.

Moments later, you cornered me as my food items were being scanned and asked me "What do you think about all this stuff they're saying about Fosamax?  Should I stop taking it?"  I was unprepared for such a question, because my navel oranges were bumping into the large globe artichokes and threatened to clog the upstream progress of the red seedless grapes onto the rubber rolling mat that conveys the groceries inexorably towards the bagging platform.   

Tales from the Crypt: On Call Page Updated

On-call archives has made it to the R3 year.  Go read it!

A snippet:

...Geez, there's going to be another C-section. The hospital has recently changed their policy allowing a woman to labor after a previous C-section. We were not meeting all of the stringent requirements set out by the hospital's insurance carrier, so the administration decided we could no longer assume the additional risk of permitting attempted vaginal birth after Cesarean section (VBAC). This means that all women who were unlucky enough to have a C-section for their first pregnancy now must be delivered by repeat C-section, without ever attempting a vaginal birth. The policy change has resulted in a lot more C-sections, longer hospital stays for mothers and babies, and a lot of bad feeling among those of us who believe that VBAC is an important birth option to offer to women. 

Residency Work-Hour Reform: Is this progress?

Thanks to Dr. Happy, I found MedSchoolHell's mention of an upcoming IOM proposal to reduce resident work-hours from 80 to 56 hours per week.

I have mixed feelings about the proposal. On one hand, when the original movement to reduce resident work-hours was proposed, I was all for the change. 

Birth Story #343: An Open Adoption

I'm reading a great book entitled The Girls Who Went Away, by Ann Fessler. It's social history of birth mothers in the United States during the post-WWII years until Roe v. Wade was passed in 1973. During that time, unmarried women were frequently sent to maternity homes to await the birth of their child, then were pressured to surrender the baby for adoption. These young women rarely received adequate counseling about pregnancy, childbirth, social services, or alternatives to adoption. Fessler recounts the pressures they faced from social workers, peers, and their own families to surrender their own children, and the emotional devastation that followed this event. It's a gripping read and I highly recommend it. If you have a Kindle, the book is available in electronic format as well.

Reading The Girls Who Went Away got me thinking about a young woman whose birth I attended a couple of years ago. Let's say her name was Caroline.  

Tales from the Crypt: On Call Page Updated

There's a new On-Call post available to read here. Check out the landing page for a complete listing of on-call posts.

My New NEIGHbor

You know you live in the country when you live next door to horses.

Here's the latest arrival: baby boy horse Scooter, only two hours old.

The Weekly Wrap: May 16-23, 2008

A few blog posts that got me thinking this week:

• Dinosaur's post about the slippery slope we encounter when we go the extra mile for a noncompliant patient. 
• Dr. Happy's to-the-point post on the complexity of hospital medicine--and why doctors are still needed in the age of the midlevel provider.
• Dragonfly's stand on empowering the helper. You go, girl!    

The Ambien Incident

I often take a sleep aid when I'm not on call.  If I don't, and I've been up a lot the preceding nights, I tend to wake up at 2 A.M. and stay awake. This doesn't do much for my bedside manner the next day. Taking a sleeper on non-call nights has always seemed like a safe thing to do, until recently. Here's the story:

Tales from the Crypt: Updated

Just posted another edge-of-your-seat report from my residency call nights. If you need a reason to be glad you're not an R2 anymore, check it out.

Case #1: On a Whim

A 45 year-old man was brought to our hospital via ambulance after being found unresponsive at home. He works as a non-clinical staff member at the hospital and is known and loved by all. En route, he is somnolent, breathing about four times a minute, and has a normal blood sugar.

By the time he arrives in ER, he is on 15L oxygen via a non-rebreather mask. His peripheral O2 saturations are 70% on room air, 94% on the 15L. His core temperature is 88 degrees Farenheit. He is given a dose of Narcan and wakes up briefly, although he immediately dozes off again. His respiratory rate increases from four to ten times per minute and he appears to be guarding his airway. His urine tox is positive for cannabis (almost universal in this county) and methadone. He can't give any history and none of his distraught family can provide me with an accurate medicine list.

Tales from the Crypt

I used to write another blog when I was a family practice resident. The blog is long gone, but I've saved a few posts I was especially proud of, in which I reported a blow-by-blow account of nights on call. People used to be interested in reading these posts, and perhaps they still are (although the taste for stories of doctors running around like lunatics might be waning now that there's been such a glut of hospital-based TV shows).

I've made a landing page for these old posts, because they tend to be lengthy and I don't want to clog up the front page of Rural Doctoring with an awful slab of words all the time. Brevity is not the soul of my wit, I'm afraid. There's one call post already available to read. I'll post the rest of them over the next few weeks.

So, Maybe No One Should Get Sick in August

Here's an article about some hospitals near me who are going to be lucky enough to receive payment for their MediCal patients in August.  Others are not going to be as lucky; while the California legislature struggles with a new budget, they suspend MediCal payments for part of the summer.  How many other essential services are expected to be provided for free for an entire month? 

Los Angeles Times: Prescription Drug Diversion

Photo Credit: Iowa Department of Public Safety

The LA Times is running an article on the impact of prescription drug abuse on urban Los Angeles.. I suspect most of us have been burned on this issue and have adjusted our prescribing accordingly. In my case, I was torn between my desire to provide enlightened pain management and the evidence of diversion by the minority of patients to whom I prescribed schedule II drugs.

It became a case of a few bad apples, and those few spoiled the whole bushel. One of the major reasons I left primary care is because I was tired of the all the record-keeping and fact-checking I had to do for my schedule II patients, most of whom were appropriate in their medication use but all of whom needed monthly refills on a certain schedule, so if I was off by even a day it created a cascade of phone calls and drama for my clinic. A few things the LAT article did not address that I have observed in my rural community:

1. The title of the article asserts that "Prescriptions supplanting illegal substances as drugs of choice," but it should be noted that prescription drug abuse provides an entry point to illegal drug abuse. I had one patient who came to me for Vicodin after a car accident. Within a few months he was scoring OxyContin off the street, and before the year was out, he was shooting heroin.
2. In economically depressed rural areas, prescription drug abuse thrives because people rely on the money they get from selling their prescriptions. Last I heard, OxyContin was going for $1 per milligram, so a patient taking 40mg twice daily could sell half their monthly supply for $1,200 and still keep half for their own use. For this kind of money, even non-criminal retirees will divert their prescriptions to supplement their SSI income--I've met 70 year old grandmothers who have done so. Believe me, I'm not trying to justify this practice, but I've pushed a few families into economic collapse by restricting their access to schedule II prescriptions.
3. Prescription drug abuse accounts for a significant number of preventable deaths in small counties. For example, in the county in which I live, the successful suicide rate for 2005 was 18 times greater than the national average, and prescription drug abuse was implicated in the majority of those deaths. Furthermore, deaths from accidental overdoses in this county exceeded both state and national averages. People who die from drug-related suicide and overdose tend to be younger than those who die from non-drug related causes, so the effect of this trend over time is to rob a community of its youth.
4. The not-so-hidden cost of prescription drug abuse includes the hundreds of thousands of dollars of public money spent treating overdose patients who actually survive. I work at a very small hospital and we regularly have 4-6 overdose admissions per week. All of them get a head CT, IV fluids, and more than a few need a Narcan drip for a few days. I have no idea how much this is costing my community every year, but I can tell you this: we can't afford it.
5. A truly hidden cost of prescription drug abuse is its impact upon the primary care shortage. As I mentioned above, escaping the schedule II treadmill was a significant contributor to my decision to withdraw from primary care, and I know a number of other hospitalists who were similarly influenced. How many other doctors are making the same decision? Their numbers are hidden among the other, more measurable reasons for leaving primary care (better hours, higher earning), and in the desire not to appear unsympathetic to treating pain in general.

These are a few thoughts I had upon reading the LAT article, but I know they in no way fully unpack the consequences of prescription drug diversion. I'd love to know how the rest of you are dealing with this.

Oh Deer

I always wanted a house off the main road with a bit of land around it, and that's what I've got. Just to give you an idea, here's the view from my back yard:

Sometimes, Doctoring Means Having to Say You're Sorry

I think this makes us all feel nervous, but I've supported the idea of acknowledging mistakes for a long time. You can't avoid mistakes without examining the ones you've already made.

Pondering Change: Healthcare Shortages in My Town

So far, 2008 has been a roller-coaster ride for the medical community in my neck of the woods. Some of the major events:

1. Three primary-care internists closed their practices at the beginning of the year. Their mostly geriatric patients are still in the process of finding new doctors.
2. A local prenatal care provider also closed her office. She practiced with two midwives, and between the three of them, delivered 25-30 babies every month. The majority of her clients have transferred their care to my clinic, where we have five prenatal care providers but are only used to 12-15 births per month. Now we are facing 35-40 babies per month through the summer months.
3. A family doctor who specialized in pain management also closed his practice. His pain patients, many of whom receive primary care at other offices but rarely saw their PCPs, are now re-establishing pain management contracts with these PCPs. Because the pain specialist practiced--shall we say--beyond the comfort level of the rest of the medical community here, the influx of his former patients has been causing a lot of distress among the rest of us.
4. Two hospitalists have resigned from my group, making it impossible for us to provide 24/7 coverage for our community hospital. Solutions are being proposed, but none of them look promising

Remember when you were a medical student and you thought your job was going to be showing up at the clinic or hospital and seeing patients? You thought the only sacrifices you were going to make were long hours, sleepless nights, and exposure to bodily fluids. Right? Wrong! The biggest sacrifice I've made recently is the investment in time/anxiety/energy/earning potential towards solving the shortages above, especially #2 and #4. I've spent more time attending meetings, rewriting contracts, generating call schedules, and preparing payroll than I have staying current with CME this year. Didn't get paid a dime for all that work, and I'm certainly no smarter.

I'll take bodily fluids any day. More anon.

Almost 500

I keep a book with the names of all the women whose births I've attended. It starts with the first baby boy I delivered as a fourth year medical student, and ends with the little boy I delivered last Friday. During my third year of residency, I mislaid the book for several months, so I missed at least 40 births during that year. I gave myself a low estimate of 293 births by the time I graduated; the actual number was probably higher.

While bringing the book up to date last weekend, I was amazed to discover that I have delivered 461 babies during my short time as a family doctor. That includes two sets of twins and a whole bunch of second babies for women whom I'd attended for their first birth. It does not include C-sections, which I never count. Along with date of the birth and the woman's name, I make notations about the circumstances of the birth: "I arrived to see someone else. She was on her hands and knees at the nurse's station, wailing."

Four hundred sixty-one births. That's almost 500, a number I associated with wise women and elders in a community. Me? Maybe I was wrong.

From time to time, I'll write about a memorable birth story. Glad I kept track all these years.

Remembering = Consciously Not Forgetting

When I entered medicine, I believed I would never forget important experiences or core values. Every clinical emergency was engraved on my mind, every uplifting moment, every unexpected grief. With each key moment in my working life, I believed my commitment to hard work, compassionate care, and intellectual purity would be etched deeper and deeper into my absolute Self. Memory and Identity were thus firmly entwined; without memory, there would be no identity as a doctor. The forgotten self cannot attain enlightenment.

Real life has turned out to be a bit different than the ideal. I remember plenty, but I forget almost as much. Key moments from medical school have degraded into a greyish soup of recollection (was that woman with squamous cell cancer of the jaw Mexican? no, Caucasian. She had photos of her cats in her room....), while those from residency retain some of their cinematic exactness, but are losing emotional impact.

With this inevitable forgetting comes a muddling of identity. When I started my first real doctoring job, I wanted to live the Dream of Family Practice: full spectrum family care, babies, pregnant women, old people, midnight admissions to the hospital, before-dawn births, Rockwellian hand-holding all day in the clinic. I had plenty of memories from my training to bolster up the Dream. Then real life took over, and everyday disappointments, minor triumphs, and sheer exhaustion began to chip away at the Dream. Gradually I removed bricks from the foundation--inpatient pediatrics fell by the wayside, then primary care medicine--and the relief at having found a manageable middle-ground replaced the old key moments in my concept of Self as Doctor.

Since this shift, I struggle with a nagging sense of failure, of having given up on the Dream. Yet the core of identity is still there. The changes I've made will help me deliver the services I still provide with more skill, attention, natural compassion--right? I believe so. I hope so. As I make these transitions, however, I return again to the core of memories that have proven (and occasionally disproven) my idea of myself as a Family Doctor. Perhaps I can't hold onto their every exact detail, but I can prevent their essence from escaping by the simple act of writing them down.

Here they are.