Rural Doctoring

Because If It Weren't Chaotic, It Wouldn't Be Life

2009-07-13T18:32:07-07:00

More reasons than usual for the dense silence on this blog lately. Noo was hospitalized last week with severe bilateral pneumonia, intubated, and transferred to Macy's, where she is slightly better and getting tapered off the vent.

I had a few bad days after she was hospitalized. My hospitalist colleague and friend--who deserves his own nickname on this blog, so let us call him Smurf--and I were in our last week at Gimbels and covering the whole hospital with no local backup. Thank Xpress Hospitalists for that, the rotten bastards. Anyway, even after Noo crashed on the floor, needed urgent intubation, on a day when I was making rounds, I still had to keep working for several days, because Smurf--bless him--couldn't cover Gimbels all by himself, and I wouldn't let him drown in the sea of chaos of 24/7 call. I should write about this some day, the extreme oddness of being both family and doctor in the same damn hospital, but I don't have the heart for it at present. Thank goodness it is over.

Now I'm off work but waiting for Noo's convincing recovery. I know enough about critical illness not to make assumptions. All I know is to take each day, one by one, as we all should, every day.

Dr. Wordsmith

2009-07-05T19:36:10-07:00

The other day I heard one of our nurse's aides use the word "parsimonious" correctly in a sentence and I was stopped in my tracks.

What does it say about American culture that months go by in Rural County with nary a three-dollar word in use? Not that three-dollar words are better than the discount variety, but I miss the wonderful surprise of hearing an ordinary statement expressed in extraordinary words.

Maybe this is why I enjoy the works of Shakespeare. When Falstaff says "I am the veriest varlet that ever chewed with a tooth," oh, how I know how he feels.

The Plan, For Now

2009-06-22T14:58:20-07:00

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:

1. Macy's, my traditional nemesis, is still using Hospitalists-R-Us to provide inpatient services, and they are quite eager to employ me. Because they have only one full-time position available, I am splitting it 50-50 with my friend and colleague who is also set adrift by our mutual decision to leave Xpress Hospitalists.
2. Another hospital, which is new to these ridiculous chronicles of rural medicine and which I shall call Nordstrom, has a hospitalist program nominally run by Xpress but with a much more canny and involved site director who has managed to make a successful program despite the general incompentence of the Xpress administrators. Nordstrom is a member of a successful nonprofit healthcare organization which has managed to do pretty well during the last decade, and they are committed to expanding the Xpress program there, so there is plenty of work for my friend and I to thrive. The major downside of working at Nordstrom is the commute: it is located in the county immediately north or Rural--let's call it Extra-Rural--about a seventy-five minute drive away. Too far for a daily commute, so nights in a dismal hotel room are in my future.

Strangely enough, I don't mind the idea of working at Nordstrom at all, despite the commute and the inevitable necessity of proving myself to a brand new medical and nursing staff. Let's face it, hospitals are clannish places and everyone casts a jaundiced eye over the New Doc in Town. I know this because, on some occasions, it has been my eye which has swept its yellowish gaze over the work of journeyman physicians. Never let it be said I can't take it as well as I dish it out.

Being the New Doc at Nordstrom is nothing compared to the bitterness of working at Macys. Even though it will be an easier transition, because I already know the consultants and the services there, and many of the ranking medical staff have been very supportive and welcoming of my decision to leave Xpress, I still harbor old grudges against the place, after having been the victim of some truly stupendous outrages at the hands of its doctors. It is going to be difficult to wipe the slate clean.

To stay on the safe side, I have signed up for only a couple of day shifts in order to get an orientation to the program, and will switch to night shifts as my regular Macys gig. I suppose this makes me a nocturnalist. I'm not a big fan of night shifts, but at least I won't have to participate in the daytime hospital culture. By this I mean the unending chatter, committee meetings, staff well-being celebrations, raffles, and daily reminders from the administration to pull yourself together which sometimes feels like you're getting pecked to death by birds. This was bad enough at Gimbels--dear old Gimbels--and I'll be tarred and feathered before I get pecked at by the Macys flock.

Another Reason Why Family Medicine ROCKS!

2009-06-19T18:56:19-07:00

Here's an article about doctors from my residency alma-mater who provide free care to the homeless in Salinas, CA. I did a rotation at the free clinic when I was a second-year resident, and reading this article makes me homesick for those days.

It's always good to remember where you came from.

A Sick, Unruly Kind of Love

2009-06-15T20:27:00-07:00

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.

Then the surgeon left the room to see his patients, and I was left alone with the osteopathic medical student who has been running around with us these days. I don't know how much internal medicine she's learning, but she knows a hell of a lot more about the economics of staffing a hospital than I ever learned in med school. Anyway, I've been ranting and raving too much in her presence, so I said aloud: "OK, today I'm not going to start one of my tirades. I'm not going to do it. We all know about the echo disaster, we all know you can't get a PICC line here at Gimbels, so I'm not going to go on and on about it." I took a deep breath in and smiled at her, then looked down at the orders I was trying to write. "The stupid thing is," I said, still looking down, "I don't really want to go. I don't really want to leave this place." And then I started to cry.

It's always a bad sign in a hospital when the attending physician is reduced to tears at 9:30 in the morning. It means discharges will be late, and core measures will not be met, and the morale in the hospital will lapse before the first wave of busyness hits the Emergency Room. So most of us internalize our little griefs and get on with the work, but on Wednesday, I hit my internal limit and I cried in public.

I don't know when, but somewhere during my adult life I fell in love with hospitals. I've been working in hospital buildings since I was twenty-three years old, and I suppose the bad ventilation in the buildings has addled my brain, because I tend to develop these Baroque affairs with any hospital I work in regularly. Sick, but true.

What is there to love about a hospital? Lots of things. I love the way the lights stay on twenty-four hours a day. I love the collections of newspapers clippings and memos which accumulate on any spare wall space on a hospital unit. I love the personal photos nurses tape to their lockers, and I love knowing where they hide the emergency stash of Hershey's miniatures. I love the clutter and disarray of a charting room: the collection of old coffee cups and bits of confetti from punching holes in lab results littering the floor, a textbook left open on the counter and shoved aside, the rabbit-like multiplication of paper clips which gather in any drawer.

I love the way the housekeepers patrol the hallways, with looks of mixed dread and affection for the state of our worn linoleum floors. I love the quirky equipment, such as the office chair which always tilts forward and threatens to eject its occupant into the next room, or the IV pump which beeps no matter how many times you tap the air out of the line or adjust the volume to be infused. I love the sight of the meal cart being rolled down the hallway as I exit a patient's room, because I know the patient is hungry and there is something coming for him to eat. I love the fact that, even if the food is not very good, it is made with a great deal of pride and care. I also love the awkward moment when the laundry cart makes its way down the hall and has to be maneuvered by its handlers around the meal cart, laundry hampers, and vital sign machines we can never quite stow away properly. I love the cheap, thin linens hospitals stock, so thin but so plentiful, you can grab an armful of towels and never worry about running out.

I love our volunteer's gift shop. They sell Burt's Bees products and locally-made chocolate bars, and Moleskine notebooks. Every week they sneak out a box of Sees candies to Med Surg for the nurses, gift-wrapped no less, and I love the way we can demolish that box of candy within an hour.

I love knowing where all the coffee makers are, and which units stock Coke and which stock Pepsi. I love sneaking into the cafeteria at night and raiding the ice cream freezer. I love the way wooden tongue depressors can be used as cream cheese spreaders. I love the way unit clerks collect the little plastic tops that come off of medicine ampules. These fill dozens of mason jars in a number of local homes, I am told, to one day become a craft project. I have a jar of them myself.

I love listening to the nurses problem-solving in the background, even though I wish fewer of their solutions involved asking me questions. I love the way our pharmacists make rounds and nudge me good-naturedly to renew my TPN before the sun goes down each day.

I love watching the staff executing the same, tedious, time-consuming process of taking in their patients, getting to know their problems, their personalities, their individual quirks and universal challenges. I love the way most of them manage to create an individual healing experience for so many different kinds of people. I love the way even a ward clerk, who has no medical training, can answer a patient's call bell with the expectation, the hope, of doing a good thing. I think a hospital is a unique setting for that set of expectations, far different from a corporate office, and closer to a church than you might imagine.

I will probably come to love another hospital as much as I love Gimbels, but knowing this doesn't make the leaving any easier. Neither did the discovery, upon my return from the restroom where I bawled my eyes out for ten minutes, of a fresh box of Kleenex left at my desk, its cardboard opening carefully torn out and illustrated with a Sharpie-drawn valentine.

Sometimes, the Inmates Run the Asylum

2009-06-07T19:19:31-07:00

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:

1. The main issue in our conflict with Xpress was their failure to expand daytime staffing at Gimbels. When we signed on, they said they thought Gimbels needed two daytime hospitalists but they wanted six months to gather data on our census. These six months included the entire last winter, a brutally busy season, during which time I regularly saw 20+ patients. (Many hospitalists I know see 20+ patients, but they don't work at hospitals like Gimbels, which is not known for the efficiency of its support services.) After the 6-month period was over, we asked Xpress "Well? What about that second hospitalist?" They said the program at Gimbels was losing money and they couldn't expand the staffing at this time. Humph. Should've seen that coming.
2. Despite a pledge not to take on more patients, Xpress went behind our backs and made an agreement with some of the community doctors to provide inpatient care for their practices. Although Xpress did not make the ultimate mistake of agreeing to take on these practices completely, they created a completely nonsensical proposal to accept the new patients up to a certain census, after which the community docs would admit their own patients and follow them during weekdays. The proposal would have had us covering those patients at night and on weekends, and potentially required us to make multiple hand-offs during the day as the community docs signed out individually to the daytime hospitalist, who would then have to parrot back the patient's information to the nighttime hospitalist. As we all know, hand-offs are a particularly vulnerable point in a patient's hospital care, and any proposal to increase them is--quite simply--a horrendous idea.
3. Xpress also regularly failed to respond to our concerns, and generally acted like absentee landowners. They tried to impose a monolithic corporate model of how a hospitalist service should be run, instead of trying to individualize the program for Gimbels. It should be noted that part of their pitch to us was the opportunity to "make your own mark" upon the program. Uh, not.
4. Although we managed to negotiate a more acceptable arrangement with the community doctors in #2--making our own mark out of an Xpress foul-up--we knew the end was in sight. The week before last, I attended a meeting with the Xpress management team and demanded to know whether they had reconsidered funding the program for more staffing. I knew they were not going to provide a second full-time hospitalist, but I had proposed an interim solution which would have effectively provided a half-time day hospitalist so we could take on all the community doctors' patients. I reminded the management of my proposal, and it was immediately shot down as too expensive. I asked them if they were capable of providing any creative solutions to our problem, and one of the suits said, "Well, Theresa, creative solutions require input from a number of sources." This sounded exactly like Dilbert-speak to me, so I handed in my resignation. A few hours later, so did my good friend and co-hospitalist. We work as a team.

So that's the big news. Of course there is an upside as well as a downside to leaving Xpress, and I'll try to post about each side in subsequent entries. Needless to say, I'm furious with Xpress, annoyed with Gimbels for contracting with Xpress, and emotionally exhausted by the whole experience. Yet I'm grateful for so many things--Noo is doing extremely well, and I've got jobs lined up already--so believe me, I'm not fishing for sympathy. Life goes on.

R.I.P

2009-05-31T22:33:34-07:00

Dr. George Tiller.

Dr. Santell's Rounds: The Long Goodbye

2009-05-24T18:24:45-07:00

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.

We hospitalists are a peripatetic lot; apparently a quarter of us plan to change jobs within the next two years. It's easier to contemplate job change when you're a hospitalist, compared to someone in private practice, for instance, but I know a lot of primary care doctors who have been moving around, changing jobs, changing roles, all in an effort to find a decent balance between job satisfaction and an adequate salary. It seems medicine is evolving in the same way American industry has: away from the ideal of spending one's entire career at one organization, toward job change, mobility, uncertainty.

During my recent week of negotiation and back-room intelligence-gathering, I thought about Dr. Santell a lot. He had a low tolerance for bureaucracy, and I would like to believe he'd be on my side, but I don't know how he'd feel about the prospect of me giving notice and changing jobs. He spent almost forty years at the same medical center, showing up to work seven days a week, fifty weeks out of the year.

Not that he didn't consider leaving. One of the most popular stories about Dr. Santell had to do with his almost-retirement. Several years before I arrived at my residency hospital, he surprised everyone by giving notice to quit. He said he was going to retire and gave no other reason for his departure, although it was well-known he was unhappy with the hospital administration at the time. Anyway, he put in his notice, everyone wailed and gnashed their teeth, and someone managed to pull themselves out of a blue funk long enough to organize a going-away picnic at one of the local parks. This was very much against Dr. Santell's wishes; he was not a sociable man and he didn't like to bring a lot of attention to himself. The day of the picnic was overcast and misty, and almost a hundred people showed up to pay their respects to the great man. Apparently he showed up reluctantly and didn't stay long, but that was all right with everyone in the end, because he didn't stay away long either.

Two weeks later he was back on the job, making rounds with the residents as if nothing had happened.

I don't know what kind of changes the hospital administration managed to make in order to entice Dr. Santell back, if any, but I like to believe loyalty to the hospital and its residents had a lot to do with his decision to return. I know he didn't like change in any form, but I believe he could have gone on to another job or another pursuit and done well, so there was no desperation in his choice, only loyalty, curiosity, and perhaps a determination to see things through, come hell or high water.

I must confess, the memory of Dr. Santell influenced my decision to stay on at Gimbels last week. It's not as if I need the job. There's plenty of work to do in Rural and its environs, and I can be working somewhere else tomorrow if I wanted to. But I don't like to give up that easily. I want to see things through as long as I can. Maybe I'll get a picnic out of it, if nothing else.

The Bread and Circuses Memo

2009-05-14T21:42:52-07:00

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.

Monday started Hospital Week with a bang, thanks to the volleyball picnic social hosted in the lovely grassy area behind the Labor and Delivery unit. Everyone thought it was a hoot to buy the advertised bag lunch and take their places at the picnic tables near the volleyball net. Too bad the Med Surg nurses were so busy trying to get patients discharged safely to do much more than inflate the ball, but that's okay because springtime in our chilly Pacific Northwest climate drove almost everybody back inside to finish lunch in the relative warmth of the cafeteria. Night shift was disappointed at missing the chance for fun in the sun, but they are already plotting next year's Midnight Madness Water Polo tournament.

Tuesday's Ice Cream Social is always a crowd favorite, especially with the addition of this year's 1950s-theme costume contest. All those really annoying overhead announcements to "recall the era of slickbacks and poodle skirts" inspired the Medical Records staff to show up looking like the cast of Happy Days. However, it was disappointing for the ICU nurses to discover how badly saddle shoes scuff the floor when they have to turn a morbidly obese intubated patient in a bariatric air bed with malfunctioning position controls. Perhaps next year the theme could be weight belts and hydraulic lifts.

Wednesday we escaped to the South Pacific for the Hula theme costume contest, won by Becky in Central Supply, who delivered angiocaths and sharps containers in a grass skirt and crown of plastic tropical blooms. This time, the Med-Surg staff got into the spirit of things by wearing Hawaiian print scrubs, which are really great as work gear because they hide the unsightly bits of sputum and dried-up alcohol gel we all accumulate during a twelve-hour shift on the floor. Even more touching was the Staff Appreciation ceremony held in the Adult Day Program trailer, where hospital staffers who have endured five, ten, fifteen, twenty and--god bless them--thirty years at our facility received a Certificate of Achievement and a lovely fruit basket for their loyal service. Once framed--at their own expense--these Certificates will be a source of pride and nostalgia during the lean years of retirement you are not helping fund with the no-match 401(k) plan offered your benefit package.

"Yeeeeee-ha!," we exclaimed upon our arrival on Wild West Thursday. The plastic rodeo decals over the windows of the cafeteria were a huge hit, as was the life-sized wooden coffin one of the boys from Plant Ops leaned cheekily against the donut display. We all appreciated the free Western-style barbecue for lunch. I mean, how many places can you see a hospital CEO dishing out tri-tip sandwiches to the working stiffs? Not at any of those big-city hospitals, I can tell you that. However, there's a petition circulating around the ER to expand the options on the cafeteria-style health plan available to your hardworking cowboys and cowgirls. People might just give up the tri-tip next year for a few preventive health care visits, assuming they all have primary care doctors, which are getting about as scarce as five-dollar copay.

Just when we thought we couldn't have any more fun with our scrubs on, we were off and running to the chopper pad for M*A*S*H Friday. Off with the Western wear, on with the combat fatigues. I think you were quite wise to confiscate Frank's field rifle and ammo belt, if only for his own safety, because it seems he's in charge of rewiring the new CT scanner suite and installing steel panels in the walls separating the scanner from the doctor's charting room. Speaking of the new CT, we're all pleased to see you investing in all this shiny new technology, but is there any way we can upgrade the paper-and-pencil requisition system? We'd all like to see what the new scanner can do, but it's hard to get any scans done when ten percent of the requisitions disappear between the Med-Surg clerk's desk and the Radiology office.

In conclusion, National Hospital Week was so much fun we're already looking forward to next year's festivities. If you're looking for suggestions, maybe you'll consider skipping the ice cream, tri-tip, raffle prizes and fruit baskets, and do something to improve the hospital instead. Boost the nurses' salary, hire more weekend ultrasonographers, repair the wall lights in room 104, build a covered walkway between the hospital and the lab so people don't get drenched running samples back and forth in the rain, and while you're at it, can we get same-day turnaround on TSH tests and hepatitis panels? Just an idea, consider it at your leisure.

Sincerely,

The Upbeat Malcontents

Who Knows?

2009-05-10T21:29:02-07:00

A certain quiet has fallen over this blog in the past couple of weeks. There are a number of professional upheavals going on in Rural, none of which I care to broadcast here but all of which distract from the more pleasurable pursuits of life, such as writing. Have no fear, Noo is doing extremely well, the sun is shining, the cats are fat and sassy, and I think I'll end up on my feet after the smoke clears. Fingers crossed.