Rural Doctoring

Rural Hospitalist Tip #1: It's Just Like Falling Off a Bicycle

So I've been having one of those funky runs of call in which it seems everyone crashes on my watch. Patients who were as stable as can be on the previous shift suddenly become obtunded or oxygen-starved the minute I've gotten sign-out and the other hospitalist(s) have left the building. This happens to everyone--after all, the patients are in the hospital for many reasons, one of which is the risk of getting sicker--so I'm trying hard not to take it personally.

This Says It All

OK, Maybe Congress Can Gnaw on THIS Problem Next

The pediatric rooms at Nordsrom are equipped with special alarms to deter would-be kidnappers. When activated, they trigger a truly appalling siren at the RN's station, the kind of sound which can strip paint off the walls. Unfortunately, they malfunctioned the other day and would not turn off. We were all in danger of being driven insane, but fortunately the Plant Ops guys managed to rig up a noise-deadening system:

This is a microfiber mop balanced on top of an adjustable desk chair. You can't see it, but there's a 3-ring binder between the two to keep the mop tightly in place. It didn't kill all the sound, but it made the decibel level tolerable for a couple of hours until the snafu was fixed.

Looks Familiar to Me

I was random link-clicking today and found this photo gallery, which could be a portrait of an average hospitalist night at Macy's. 

Never Mind the CT Scanner

Here's the most important piece of equipment in the hospital:

You got it, the ice machine. Just ask all those parched patients on Med-Surg which device they'd take with them to a deserted island.

Me, Abandoned by Martians

It's been several months since the space-time continuum was indelibly altered by Noo's critical illness and my decision to leave Gimbels. Whereas previously I was a bit of a chatterbox on this blog, I have to acknowledge a certain surly silence which has take the damn thing over ever since. I've never been good at change, and there's been nothing BUT change since July, and all I could do was surrender myself to it and see where it would take me. Most of the time I feel like one of those ordinary citizens in the movies who, through no fault of their own, wake up at the center of a David Lynch movie, apparently plunked there by Martians. A video montage of this movie might include scenes such as:

Comparison Shopping for Rural Hospitalists

Recently a reader asked me why I left rural practice, and I took this as a sign that my recent job-hopping has made me seem like one of them fancy-pants, highfalutin' cityfolk doctors who make such a stir on TV. At one time, I too believed a country doc stayed in one town for thirty years, delivering babies and burying octogenarians, until you finally drop dead in the office one day after seeing a clinic full of patients. Modern doctors seem to move from job to job, role to role, throughout their careers, as mobile as information technology supervisors, customer service representatives and hedge-fund managers, regardless of the demographic they serve.

Crawling Into The Hole

OK, I'm starting my second run of night shifts at Macy's, this time SEVEN in a row so I'm hoping my day-to-night transition method is going to hold up:

Rural Career Tip #1

Do NOT, under any circumstances, start working at two different hospitals in the same month. You'll mis-remember all the door codes, wear the wrong ID badge, and won't be able to tell all the Amandas, Daves and Chris-es apart.

Trust me on this one.

Wanted: Nocturnalist Ruralist Hospitalist

Couldn't resist the title--have you noticed how sub-sub specialized medicine is becoming? Tonight I begin the first run of night shifts at Macy's (four nights in a row, a mere warm-up to doing as many as eight). I haven't had regularly scheduled in-hospital night shifts since residency Night Float rotation. I'm a bit rusty at the night routine and have to re-create the correct timing of coffee, protein-rich meals versus carb-rich meals. Meanwhile, the white noise machine and blackout curtains haven't arrived, so this weekend might be less slick than I'd hoped. Cross your fingers for me.

There's a New Kid On the Playground

So I've started working as a hospitalist at Macy's, having worked four day shifts to get a feel for the place and a lay of the land. I've located all the bathrooms and all the working fax machines. I have a yeoman's grasp upon the EMR, which is pretty good and makes life as a resentful Gimbels refugee at least 15% easier than that of a harried Gimbels hospitalist. Everyone is very nice and does a very professional job and I really have nothing to complain about. Not that I'm going to let this stop me, no sir-ree.

The Brave New Hospitalist

If you've been following the details of my little saga closely, you might remember that immediately prior to Noo's illness I was bracing myself to leave Gimbels. Actually, Noo was hospitalized during my last week there, and the emotional upheaval of leaving Gimbels was overshadowed by the emotional turmoil of worrying about her. This was a mixed blessing at best, because now have the relief of knowing Noo is getting better, I still feel unresolved about leaving Gimbels. I suppose this is how the people who believe they were abducted by aliens feel.

The Plan, For Now

I admit, I have been hoping for a last-minute rescue--in that way you learn to do in early childhood, from watching too many cartoons--which would keep me at Gimbels. Well, none is forthcoming, and I have been busy devising the following back-up plan:

A Sick, Unruly Kind of Love

Last Wednesday I was rounding on the hospitalist service and I got into one of those time-wasting gripe-fests with one of the general surgeons. He was beefing about an incentive spirometer he'd ordered for a patient the day before, which never materialized, and I told him I'd had to transfer a patient to Macy's in order to get an echocardiogram over the weekend, and then we both shook our heads and talked about how Gimbels was falling apart. This is the kind of conversation you have when you've decided to leave a job.

Sometimes, the Inmates Run the Asylum

I haven't been in a blogging frame of mind lately, and I blame it on professional chaos. In a recent post I mentioned that my hospitalist colleague came very close to resigning from Xpress Hospitalists, the name I choose to use for the staffing agency who took over our hospitalist program when we could no longer staff it ourselves. Well, things have evolved since then. Here's a precis:

Dr. Santell's Rounds: The Long Goodbye

I've been through a bumpy ride professionally the past several months, and last week my colleague and I were on the verge of giving notice and looking for greener pastures, but a certain amount of ingenuity and iron nerve (mine) and a large amount of diplomacy (his) managed to save the situation, at least temporarily. I would say "phew" except I don't really feel relieved. Practicing medicine is difficult, but making a living, holding down a job, keeping one's foot firmly planted in the realm of acceptable working conditions is even more so.

The Bread and Circuses Memo

Dear Hospital CEO,

Thank you for an eventful and fun-packed National Hospital Week. The entire staff looks forward to the annual celebration of hospital services and wishes to extend their gratitude--and feedback--for the activities presented this year.

Why Doctors Should Read Newspapers

One of our intermittent hospitalists previously worked in suburban and urban hospitals, and has found our two-ring rural circus a bit challenging. I knew he was settling in nicely when he told me the following story:

Case: My Life on the D-list

Today I worked up a 50-ish man who was admitted with altered mental status, cystitis and acute renal failure. He'd been in the hospital for just over twenty-four hours without much improvement. He wasn't hallucinating anymore, but restless, agitated, strange.

Twenty

I'm nearing the end of a gnarly run of hospitalist days. Our census has been averaging 21 patient encounters every day, all of whom need to be seen by moi. For those of you who have never made rounds, that's a lot of patients to see, data to track, decisions to make. Personally, I'd rather limit my rounds to no more than 15 patients, because I notice that's the number at which my performance peaks. The problem is we're a small hospital, with a correspondingly small hospitalist program, and right now we only have one person staffing during the day. Ow.

Warning: I Blither Aimlessly in This Post

Last week was odd, to say the least. Noo started interferon therapy, and this went smoothly--she's taking it like a champ, side effects and all. We're lucky to have some help, in the form of our Girl Friday, who can take Noo to the infusion center when I can't. However, I was able to go with her three out of the five treatment days last week, which is pretty good considering I was covering night shifts for the hospitalist service.

It's Delightful, It's De-Lovely, It's Delirium!

Recently I helped take care of a 90-ish year old man who fell down and broke his hip.  He's moderately demented at baseline, and while waiting for and ORIF--our Anesthesia department was balking at his cardiac co-morbidities--he got more than a bit delirious.  Delirium is a common hospital-based problem, especially in older patients with cognitive losses at baseline who develop an acute illness or who have a condition which requires interventions such as bladder catheterization, NPO status, ICU observation, TPN, beeping IVs, and almost everything else I was compelled to order for this poor gentleman.

If Esme Were Extremely Interested in Depravity

This post is a bit all-over-the-place.  I know it already, only after writing the first few words.  Noo and I are in Ashland, OR, to see a few plays at the beginning of the season, before Interferon robs us of any opportunities for pleasure.  I drove us up here yesterday, after completing a truly awful week of hospitalist rounds, the kind of week that raises disparate literary allusions in my mind.  At one time, I wanted to be a writer and a scholar, so I'm afflicted with disparate literary allusions from time to time.  I think these allusions are the primary occupational hazard of literary scholars.  Believe me, I prefer to examine infected wounds and gangrenous feet than wrestle with renegade literary allusions.

Hospitalist Rounds: The Great Mystery

I knew her from several other hospitalizations, all for drug abuse-related medical problems:  MRSA abscesses, hepatic encephalopathy, opioid withdrawal. This time she was hospitalized with massive ascites. Her belly was twice the size of the rest of her body and her eyes had the sunken, pinched look liver disease patients have at the end of their lives. She was only a few years older than me.

The Hospitalist Lexicon, Lesson #1

Upon being informed she will walk into a twenty-patient service the next day, all of the following are acceptable emotional responses for a rural hospitalist:

• Horror
• Despair
• Nihilism
• Hysteria
• Resignation
• Numb, emotional shock
• Dread
• Fury
• Desperation
• False hope
• Escapism
• Panic
• Pure Type-A intellectualism
• False bravado
• Grim determination

Feel free to add your suggestions in the comments. I'm going to be stuck in the hospital for a while.

"Did You Have a Nice Holiday?"

People keep asking me this question, and it makes me want to laugh because I was working over the entire holiday weekend and now I'm feeling a bit like I stepped off the last plane out of Saigon. Recap:

• Christmas Day:  24-hour shift, rounded on sixteen patients and admitted two more. In the hospital for sixteen hours but at least got to sleep in my own bed. Partly cloudy skies, followed by hail and steady rain.
• Day After Christmas:  24-hour shift, rounded on twenty patients (includes four admissions and four discharges), had a very depressing family meeting about an ICU patient. Pouring rain all day, general sense of gloom. In the hospital for fourteen hours, slept at home.
• Saturday:  12-hour shift (hooray!), rounded on twenty patients (includes another 4 admissions and 4 discharges). Had an extremely frustrating meeting with family of ICU patient and a community colleague. General sense of despair and hysteria among the patients who have been cooped up in the hospital over the holiday. Raining all day. In the hospital for thirteen hours. Slept like a log.
• Sunday: 12-hour shift, rounded on twenty patients (incluedes 3 admissions and 3 discharges, I can't seem to tip the balance in my favor), had one more challenging meeting with ICU patient's family and community colleague, had to be firm and advocate for the patient's best interests, and finally we withdrew care. He died peacefully three hours later. Feeling physically numb but emotionally pissed-off. General mood in the hospital is more subdued than yesterday, perhaps because it has been raining continuously for what seems like forever. In the hospital fourteen hours. Return home in a state of collapse.

At first, when people asked me if I had a nice holiday, I said "I was here at the hospital."  For some reason this elicited so many expressions of sympathy and general "awwwww, poor you" attitude that I was in danger of succumbing to despair. So I changed my response to "Good. And yours?" The results have been much more satisfactory. I get to hear about everyone else's celebrations and don't have to relive my own horrors. Management of small-talk is the most overlooked professional skill in medicine.

The Holiday Hospitalist

In what has become the ticker-tape of recent posts, I'll start with updates:

• My partner had her graft examined today and it looks AMAZING! We kissed the home vacuum dressing goodbye, and now she has a plain Adaptic on it and gets to move her arm a tiny bit more.
• The Mac ICU diagnosed a dead hard drive, which has now been replaced so I am glad to say I am reporting live from my own beloved G5 once again. 
• Public service announcement: Back up your hard drive regularly. Don't ask, just do.

Tweet Archive: How to Stay Awake During a Conference

I'm just back in Rural after several days in San Francisco where I attended the Care of the Hospitalized Patient, co-sponsored by UCSF and the Society of Hospitalist Medicine.  In an attempt to render my note-taking as paperless as possible I used Adobe Acrobat Pro to annotate the PDF files corresponding to each lecturer's slides.  This gave me an excuse to drag my MacBook everywhere and keep Twitter open for the entire conference.  What resulted was a line-by-line report of the conference, which has been kindly featured on Clinical Cases and Images as an example of using social media such as Twitter to share information about curent medical practice with one's colleagues.  In total, I tweeted 192 times from the conference.  Here's a selection of the top tweets:

A Pithy Observation

Some days, you run your hospitalist service.
Other days, your hospitalist service runs you.

I'm hoping to be in charge today.

The Efficient Rounder: Response to DB Medrants

At Medrants last week, Dr. DB raised several questions doctors ask themselves while rounding on patients:

1. Are we certain of the diagnoses - or do we need more diagnostic information?
2. If we are treating, is the treatment working?
3. What are our goals, or where are we going?
4. What are the patient’s goals and are we meeting them?
5. Does the patient understand the diagnosis, or the diagnostic workup?

Tweet Archive: Yesterday's Hospitalist Rounds

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:

An Update on the Rural Hospitalist Conundrum

A while ago I wrote about the ending of my hospitalist program and my options to join another group. Here's a brief recap of the choices, and a discussion of the factors influencing my decision:

• Join whatever solution Gimbels--the small hospital where I've worked for four years--put in place after our hospitalist group dissolved.
• Join Revenue-Keepers, an extension of a private practice wishing to retain the income generated by following their patients in the other local hospital, Macys.
• Join Hospitals-R-Us, a national staffing company specializing in ER and hospitalist programs.

The Hospital Yadda-Yadda

Scene: A charting room on a medical-surgical unit in a community hospital. A hospitalist enters and consults a computerized patient census.

HOSPITALIST: [counting patients] "Two, four, six, eight, ten, twelve--shit--fourteen, sixteen--"

NURSE 1: [approaching Hospitalist] "Dr. Chan?"

HOSPITALIST: [Still looking at computer] "Hi, what's up?"

Rural Hospitalists, Part Five: At a Decision Point

Over the past two weeks I've been reviewing the state of hospitalist services in rural communities. In Part Four I revealed that my hospitalist group is folding next month. This leaves me contemplating a number of new job opportunities, which I propose to discuss in this post. Once again, the hospitalist groups and hospitals I discuss below are really composites of a number of different groups and hospitals I have known and loved (to different degrees) over the past few years.

Rural Hospitalists, Part Four: The Unmaking of Feelgood

In Part Three of this series examining problems facing rural hospitalists, I described three local hospitalist models in and around Rural, CA. and compared the three programs based on patient population, compensation structure, volume of patients, and ownership of the program. Some of you may have guessed that I work for the Feelgood program at Gimbels. What you probably did not guess was that Feelgood is going to be folding next month, due to a confluence of problems, but ultimately due to resignation of two key colleagues from the hospitalist group.

Obviously this is a crushing disappointment to me. I have a great attachment to Gimbels, problems and all, and a greater attachment to most of my hospitalist colleagues. I think I rediscovered the joy and misery of belonging to a team by working with this group--something I've been missing since I graduated from residency. If there is a silver lining to the collapse of Feelgood, it is the crash course in hospitalist management it put me through over the past 12-18 months. This post summarizes some of these hard-won lessons. Some of the lessons are specific to our particular program, but there are a lot of general issues applicable to other hospitalists and to doctors searching for the right job.

Rural Hospitalists, Part Three: Examples of Hospitalist Models

In Part Two, I described two rural hospitals (fictionalized as Macys and Gimbels) and some of the tensions between them. Today, I'm going to show you three hospitalist programs at work in and around Rural. I know it seems ridiculous that a sparsely-populated rural area would need THREE hospitalist programs, but you might appreciate some of the subtleties after reading the following.

Rural Hospitalists, Part Two: Macys vs. Gimbels

I have to make a decision about my hospitalist job pretty soon. (No I'm not going into the details right now, but stay tuned.) As I consider my options, I've also been thinking about the role of hospitalists in rural communities and the role of family doctors as hospitalists. Before you can grasp what it is like to be a rural hospitalist, you need to know what the rural hospitals--and the medical community that supports them--are like

But first--a brief disclaimer: even though I'm obviously drawing on personal experiences, the hospitals I describe in the remainder of this post are actually composites of several of the small-town hospitals in which I have worked. I'm fictionalizing the hospitals to be discrete, because I have to live and work in a small community, and even though the conflicts and difficulties the hospitals I describe are largely a matter of public record, it would be a blot upon my professionalism to talk about them by name.

Without further ado, I present to you two hospitals, nicknamed Macys and Gimbels.

Rural Hospitalists, Part One: Introduction

Both Dr. RW and Medrants have posted recently on the evolution of the hospitalist movement. Although the number of hospitals implementing a hospitalist program is growing rapidly, a number of questions remained unanswered regarding outcome data and cost-effectiveness of hospitalist-led patient care and the best job description for a hospitalist physician.

Within these recent posts, Medrants raised an issue that hits close to home for me. Here he excerpts from his editorial in the Archives of Internal Medicine:

As I wrote in my original discussion, the phrase "hospitalist inpatient system" does not describe a homogeneous concept. Hospitalist groups vary in call structures and accessibility. Academic hospitalists often have very different responsibilities than community hospitalists. We need to understand the influence of these various systems on the measurement of hospitalist impact.

We also do not know how much the individual physicians affect patient care outcomes. I suspect that we all believe that some physicians consistently do a better job of patient care than do others.

As a family doctor providing rural hospitalist services, I appreciate Medrant's acknowledgement that hospitalist programs and hospitalist physicians are not uniform in composition or quality. Most of the emerging policy statements I've read tend to address the needs of the new profession as if all hospitalists were facing the same responsibilities and concerns. Many discussions on the future of hospitalist medicine also assume that training and certification of hospitalist physicians will fall under the umbrella of internal medicine, either as a subspeciality or a new specialty "spun-off" from internal medicine.

Being a selfish beast, I am alarmed at the absence of rural or family medicine perspectives in the debate about the future of hospitalist medicine. So I'm going to throw my hat into the ring. Over the next two weeks, I'm going to be posting on some topics specific to small-town hospitalist programs and the family doctor as hospitalist, including:

• Characteristics of rural hospitals and rural medical communities
• Three rural hospitalist program models
• The development and collapse of a locally-run hospitalist program
• My own professional dilemma as a hospitalist physician facing an imminent job change

By the time I get to the end of this brief series of posts, I hope I'll have made up my mind about my own hospitalist conundrum, and also made the point that hospitalists are not one type of service, nor one type of physician.

Case: Another Reason Why Healthcare is Going Down the Toilet

An 88 year-old man traveled from the Silicon Valley to visit friends up here in Rural. After dinner and a couple of glasses of wine, he tripped on a flagstone and broke his right proximal humerus and his right femoral neck. My little hospital had the great pleasure of admitting him.

Almost immediately, his three daughters started calling Med-Surg, providing phone numbers of his primary care doctor, cardiologist, and vascular surgeon. One of them made reference to two episodes of "torsades," although she really didn't know what that meant. They were obviously worried about the prospect of surgery to repair the hip. What was unspoken but equally obvious was their concern about his having surgery at "what's-that-hospital-called?" here in Rural.

Cases: Afraid of the Worst

One day on hospitalist rounds, I saw the ER had left me an admission from 2am. The sign-out read: "63 year old woman with large breast mass." I wasn't sure what that meant. Perhaps a breast abscess?

The truth was a bit more complicated. I could tell when I entered her room and introduced myself. She emitted an odor I can only describe as living decomposition. A syrupy, cloying smell reminiscent of rotting meat, only worse.

Rural Doc, CFO: More Stuff I Never Learned in Med School

Instead of writing lyrical, thought-provoking posts about the uplifiting experiences of being a doctor, I find myself preoccupied with billing statements, cash flow, accounts receivable, and countless other details essential to the robust health of medical organizations.

Cases: Are You Confused, or Are You From Alabama?

This is a real excerpt from a discharge summary I dictated recently:

This is a nice 88 year old man who returned home from a road trip on the day of admission.  He had stayed at a Motel 6 motel in [another town] and had subsequently seen an advertisement offering the chance to win a free stay at the chain of hotels by completing a customer satisfaction survey.  When he was within a few blocks of his home, he noticed there was another Motel 6 on his way and decided to go to the motel to obtain a copy of the survey.  However, when he made his request at the front desk, the staff at Motel 6 thought he was confused.  Specifically, the EMT notes suggested that he kept repeating "town and country, town and country" over and over again; this was taken as a sign of altered mental status even though the patient later explained to me, "They was asking me where I lived, and I told 'em, Town and Country Mobile Home Park."  The next thing he knew, he was being taken away by EMTs and brought to the emergency room where, based on the EMT history of "altered mental status," he was admitted for observation...

...After some discussion among the staff and with the patient of the events leading up to his admission, it became apparent that what was described as a confusional state was actually a misunderstanding.  The patient--who, at baseline, speaks in a fairly broad Southern accent, is noticeably hard of hearing, and has an extremely discursive conversational style--probably appeared confused to an unfamiliar and inpatient motel staff.

Dx:  Slightly befuddled 88 year-old man from Alabama

Dispo:  Home. Do not return to Motel 6.

The Impact of Diagnostic Errors

Bob Wachter has written a thought-provoking post on the hidden impact of diagnostic errors. The post discusses the current frenzy over preventing system-based errors (i.e. wrong drug, wrong side problems) which are made while providing patient care for an established diagnosis.  But what if the diagnosis is wrong?

It is the classic GIGO scenario: the result is only as good as the data inputs that created it.  As medical imaging becomes more sophisticated, genome mapping moves within reach, and competence in minimally-invasive surgical techniques increases, people naturally expect diagnostic accuracy to increase as well.  Why wouldn't it?

The Stack, Redux

I have a Stack of Damnation at the hospital as well as the clinic. Here it is:

And here's what I did about it last night:

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:

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.

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.

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.