My mini-retirement is scheduled to begin this Thursday. Last night I received a request to fill in hospitalist shifts from Thursday to the following Wednesday. This was a last-minute scheduling crisis which, in my opinion, could have been foreseen weeks ago. The following is a lightly-edited excerpt from my response to a friend and fellow hospitalist:
Honestly, I don't want any of those dates. My 6-week "mini-retirement" begins on 10/2 and I am not interested in working AT ALL.
One of the reasons for the mini-retirement is to teach myself the discipline of saying NO to unwanted work and to stop involving myself in every f***ing solution to every f***ing crisis at [the hospital].
So I'm saying NO
Protecting time off is a skill you can only learn from experience. Although I'm a firm believer in being available to help my colleagues if they are in a jam, I am learning--the hard way--that this kind of team spirit rapidly deteriorates into a false impression of willingness to work all the time. So I'm drawing a line in the sand.
Even if I have to use the F-word to get my point across.
Question: Which of the following people looks like a physician?
The man on the left is Pablo Gonzalez Casanova, a Mexican national and social critic, known for defending the Cuban Revolution. A very distinguished man, but not a doctor of medicine.
On the right is me, baggy-eyed rural family physician, attender of births, overworked hospitalist, and ever-hopeful blogger.
I post these photos, not for self-promotion (ha!), or even to promote the ideals of Professor Gonzalez Casanova, whose photo I chose for his distinguished mien and formal dress, but because I have lately been pondering a question: How important is a doctor's personal style?
An 81 year old man arrived in the Emergency Room with subacute onset of shortness of breath. He had a history of Parkinson's Disease and hypertension, neither of which had caused any significant decline in his quality of life although he had noticeable intention tremor when he felt tired.
He'd been hospitalized many years ago for what sounded like a soft tissue abscess that took a long time to heal. After the hospitalization, he and his wife consulted a lawyer for help drafting an Advance Directive:
Recently I've been stymied in trying obtain articles from medical journals in order to support my own research and patient care. There is no major institutional library in Rural. The two major hospitals have reading rooms but, as far as I know, no librarian support. This means that I have to work with an institutional library 260 miles away to obtain papers in journals neither of my local hospital libraries carry--which is most of them. The distant institutional library charges a $15 fee for each article sent, which makes things expensive for this independent rural scholar. Thanks to Twitter, I've found a lower-cost solution:
I have a long weekend off and I'm planning to take a brief break from blogging. Because of this, I'm posting the Wrap a few days early and only including my reading through 9/18/08, but believe me there were some plenty good posts published during that time:
I was covering Labor and Delivery one day during the second year of residency. We had the usual bustle of women arriving for labor checks, antenatal testing going on and had a few babies whose new cries punctuated the yadda-yadda of nurses, patients, and my own blithering.
Suddenly I heard my name being called to room 206. "Dr. Chan, we're having a baby in here!"
By the time I entered my intern year, I thought I'd had a lot of exposure to OB and childbirth care. After all, I'd done four rotations and delivered ten babies, a good record for a mere medical student. I had a few moments of pure hubris in thinking I'd seen enough to be ready for the large number of deliveries I was looking forward to doing at my program's hospital. In this post, I'll discuss what I learned about childbirth and maternity care in during my three-year family practice residency.
King City is a very small agricultural town in central California. I've never been there but the residents in my program used to take care of King City's patients when their own rural hospital, Mee Memorial, couldn't provide needed services. The people of King City and surrounding environs don't have many options for obtaining health care except for a publicly-funded FQHC and Dr. Harrison's private practice.
Recently, we had a 39 year-old man on our hospitalist service who presented with transient hemiplegia, diplopia, and somnolence. A brain MRI showed an acute stroke in the distribution of the thalamo-geniculate pedicle. By the end of his hospitalization, his mental status and motor abilities had normalized but he retained an interesting pattern of aphasia. He had a great deal of word-finding difficulty, although his speech was fluent and he could follow commands easily.
The last Birth Story I wrote described the worst shoulder dystocia I've encountered so far in my working life. It was a seven-minute delay between the birth of the baby's head and his shoulders, and it was the kind of seven-minute event which can change a person's life forever. I've heard of cases of shoulder dystocia in which the infant did not survive, or the mother suffered from significant injury, and I know of a number of doctors who have defended lawsuits after a bad dystocia. The outcomes are potentially bad enough that even when you have a good outcome, as I had, your gratitude may be diluted by fear. Some practitioners give up attending births after a near miss, even more change their practice style to become more conservative--becoming the kind of birth attendant they never wanted to be.
Whenever I've been involved in a scary incident, I remind myself of something I learned my intern year. I'd had a bad couple of nights on Night Float in which I'd attempted intrathecal analgesia twice on two different patients and not been able to get into the intrathecal space. Each time, my supervising third-year had to complete the procedure. So when the next night rolled around and my R3 approached me with a three year-old who needed a lumbar puncture, I hesitated.
"What's the matter?" My R3 asked.
"I've missed the last two spinal procedures I tried," I answered. "I think maybe it's better if you tap this kid, because--"
"Nope," the R3 interrupted. "You've got to get back up on that horse. You've got to do this one."
So we went up to the Pediatric unit, set up for the lumbar puncture, and--with my R3 standing behind me--I got in and did a champagne tap. Smooth and easy as if I'd been doing it all my life.
The moral of this story: If you're having a run of bad luck, keep trying. The worst possible outcome after a scary clinical scenario or a failed procedure is allowing uncertainty to take hold. Far better to try, try again than to hold back and never achieve any competence--or courage.
So, after the events in Birth Story #423, I decided to get back on the horse. Here's the story:
In the last post in this series about becoming a rural physician, I'm going to discuss joining your new community. By this point in your training, you've already explored the rural experience in medical school and residency, and you've also found a job in a rural community you like. But once you get there, how do you start life and medical practice?
A young professional can find dozens of how-to guides on how to hire movers and pack boxes, how and when to cancel utilities at your old home and install them in your new one, and how to forward your mail. But there's more to moving than relocating your coffee maker, your garden gnomes and your lava lamp collection. You have to become a part of a new community, and for a new doctor, there are some special tasks to complete and considerations to make.
As a lone hospitalist, I find solace reaching out to my online colleagues. Yesterday, as I tackled the challenges of the rural hospitalist's life, I updated my progress (and lack thereof) on Twitter. Here's a sequence of tweets, demonstrating the arc of a day at my hospital:
Nola was ten days overdue when one of the midwives I work with called me to say she needed to be induced. "I'm worried her baby's going to be really big," my friend the midwife said. "It feels huge."
Nola was a tall, sweet-tempered, strong-bodied yet heavyset young woman. Her pregnancy had been pretty uneventful but she'd gained about forty-five pounds since her first visit with us. Fortunately, a gestational diabetes screen was normal, and for that reason we'd waited until her due date had come and gone before considering induction. Now she was close to two weeks overdue and no signs of labor yet.
Over the last several posts in this series, I've discussed the training and education of future doctors. This week, I adopt a slightly different perspective and address some professional qualities I believe are important for all doctors to develop, no matter where their practice setting may be. In my experience, I've had to work especially hard at maintaining the following qualities when I'm on the job, because living and working in a small community tends to magnify a doctor's personal failings and can damage her reputation quickly indeed.
I'm writing about my childbirth philosophy in a series of posts. Like many doctors and some midwives, my experience attending births began in large teaching hospitals, in my case during third- and fourth-year obstetric rotations. In this post, I'm going to describe these experiences and what they taught me, and examine the implications of these early experiences on a learner's later beliefs about childbirth practices.
So far 2008 has been a professional roller-coaster for me. I gave up primary care at my FQHC late in 2007, thinking I'd be helping to lead our grassroots hospitalist program. The program folded, but I'm going to be continuing as a staff physician for the agency who is taking over hospitalist services at our hospital.
The summary of events fails to capture the disappointment, the uncertainty and terror of choosing the wrong job. It's been exhausting and I'm glad its over.