Rural Doctoring

Silence. Listen.

2009-10-17T10:31:03-07:00

Noo and I had to put our cat to sleep ten days ago, a very bad day indeed. I was starting a week at Nordstrom and had to drive back and forth from work to home three times that day, and it's hard to drive on rural highways when you're crying.

I've been quiet on the blog because I've been listening to myself. I realized that I've been putting solutions together for years which look good on paper but truly suck in practice. Flashing my middle finger at Gimbels and working at Nordstrom (a good job, btw, but...) seemed so reasonable at the time, but I hate being away from my home for a week at a time, and I hated missing my cat's final moments because I was on my way from 60 miles north. Not that working at Gimbels that day would have been a walk in the park, but I would have been there and I would have been able to hold her one last time. Thank goodness Noo was there. We raised this cat from a 4-week old kitten and she was like the warm pulse of our household. I don't expect everyone to understand this sentiment, but cat people will, and I honestly don't give a shit about any opposing opinions.

"Being there" is an emerging theme in my current reflections about doctoring, early middle age, the creative life, and What Comes Next. I'm going to try to get some of these reflections onto the blog but only episodically. I need to be quiet. I need to listen.

Everyone Has Her Limit

2009-09-26T20:28:59-07:00

No, I haven't disappeared off the face of the earth. Since my last post, I've been holding down the jobs at Macy's and Nordstrom and one of my cats got sick. She was diagnosed with diabetes and kidney failure, and now--in addition to being an effective nocturnalist and itinerant rural hospitalist--I am also learning how to give her subcutaneous fluids (twice a day), insulin (twice a day), and vitamin B12 supplements. She's got diabetic polyneuropathy so she can't really walk around, which means I'm changing a lot of linen and investing in waterproof crib liners to keep the house habitable.

I've coped effectively with the upheaval in my professional life, Noo's melanoma diagnosis and subsequent critical illness--but my cat getting sick sent me over the edge. So I've been crying a lot and succumbing to retail therapy and generally being fairly insane, but things are getting better because my cat is getting better, so I'm hoping to resume thoughtful blogging about the life of a rural doctor soon.

Comparison Shopping for Rural Hospitalists

2009-09-08T15:42:38-07:00

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.

Because, in fact, I have not left my rural community at all, only shifted over to the larger hospital in the county (Macy's) and expanded into the next county (Extra-Rural) to work half-time at their hospital (Nordstrom). So not only am I still a rural doc, I'm now a commuting rural doc who is in a position to know the ins and outs of every hospital in our nutty little middle-of-nowhere region.

Since announcing the painful and life-transforming news about my departure from Gimbels, accompanied by my friend and colleague Smurf, I've started not one but TWO new hospitalist gigs and have a good run of shifts under my belt at each facility. Here's my initial impressions:

Macy's

Physical plant: large-ish (three floors) and expanding, with brand-new extra-large ER/OR/ICU being built in front of the current building.
Patients: usual rural assortment of respectable middle-class, street junkies, underinsured, desperate cases, and occasional lunatics. No celebrities or Saudi princesses.
Services: most of what you'd expect in a "real" hospital: cardiac surgery, radiation oncology, dialysis, PET scans, etc.
AM labs done on time?: yes, results viewable on EMR but takes forever to be filed in paper chart. EMR is not unified under one program for labs, studies, etc.
Hospitalist staff: well-intentioned but lacking talent (except for me and Smurf, of course). Overly prone to say "yes" to surgeons and ER. Desperately understaffed. B-minus team overall.
Consulting staff: too many and yet too few of quality. Tend to dump on hospitalists ("Consult for HTN management" ordered at 5pm after elective surgery, for example). Older members of the hospitalist staff tend to consult about every little thing ("Acute renal failure? Did you call nephrology?") which creates a dependency dynamic I was not accustomed to at Gimbels.
ER staff: C-minus team. Married to the shift mentality, resulting in requests to admit chest pain patients on whom first troponin is still pending. Some very erratic ER management resulting in hair-pulling on my part (stay tuned for gory details in future post). In comparison, Gimbels used to have an A-minus ER team during the Golden Years, and my residency hospital never dipped below a C even on bad days.
Political landscape: discontent and hostile, reminiscent of Medici Florence without the poison rings. A lot of yelling and posturing and talking dirt behind each others backs.
Hospitalist per diem: 19% more on average per 12-hour shift than Gimbels, as long as I work eight shifts or more per month (i.e. bonus for meeting target schedule).
Patient load per hospitalist: 18-22, with some memorable 28-patient days which I find appalling.
My emotional landscape while on the job: resentful, despairing, but grateful to be working alone at night, when most of the nastiness has crawled back into its cave to sleep.
Professional forecast: rainy, chance of thunderstorms.

Nordstrom

Physical plant: small, single-level hospital, a lot like Gimbels but brand-spanking new. Located 75 minutes north of my home, just over my personal limit for a daily commute. Out of town hospitalists are barracked in a pretty tacky vacation rental apartment off the main drag.
Patients: same as Macy's, except relatively fewer respectable middle-class.
Services: no-frills. General surgery available, orthopedics some of the time, but otherwise nothing. Stress testing is done out of town. Patients requring pacemakers need to be transferred. A truly amazing case management staff is on seven days a week to facilitate transfer, and just two weeks ago they transferred six patients out on one day shift, including two patients to separate VA hospitals, which is something just short of walking on water, imho.
AM labs done on time?: yes, and they land on the chart the hot minute the results come out of the lab. I don't have access to them on EMR but I have never wished to because the nurses slap those babies in front of me before I have time to wonder where they are.
Hospitalist staff: mixed but overall pretty strong (B-plus to A-minus). A lot of out of town doctors who do long stretches at a time, including some old-timers who can handle anything. Long-standing site director is excellent and believes in treating staff hospitalists very well.
Consulting staff: Practically nonexistent except for surgeons, therefore we're all nice and matey because there's nothing to fight about.
ER staff: haven't met them all, but the ones I have are pretty sound. ER group is managed by the same staffing agency as the hospitalists, so the incentive to play nice and get along is strong. Haven't had any really stupid admissions here yet.
Political landscape: fairly placid, except I don't know what goes on in the back rooms. No yelling and no trash-talking so far.
Hospitalist per diem: 8.5% more than Macy's, no minimum shift requirement, and expected patient load is much more rational.
Patient load per hospitalist: 12-15 per day, occasionally up to 22 but this is a rare event (unlike the regular event is has become at Macy's). Staff and site director freak out if I see more than 12, whereas I freak out if I see fewer than this number.
My emotional landscape while on the job: placid, unruffled, mildly curious to see what will happen next. Seeing fewer patients per day means I don't get stressed out when family members show up late in the afternoon or patients want things explained to them a second or third time. Feels luxurious to me.
Professional forecast: mostly sunny and cool.

I'm still getting my head around being a full-time hospitalist and no longer in the warm, dysfunctional embrace of dear old Gimbels. I'm trying to keep an open mind about Macy's, but it is difficult because of our stormy history and some recent events on night shift which have only confirmed my worst impressions of the place. With Nordstrom, I have no history and therefore no baggage, so it is easy to slip in here and appreciate the way the place works, and what it feels like to work at a hospital where quality of patient care is not only valued but provided the resources to thrive. I only wish Nordstrom was Gimbels, or perhaps what I really wish was that Gimbels were the hospital it should be. All in all, I'd settle for Nordstrom being forty-five minutes away from home, but I'm dipping into superhuman territory here and I'd better settle for what I've got.

Crawling Into The Hole

2009-08-28T18:17:34-07:00

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:

Day before/day of the first night shift:

Day before: long afternoon nap, stay up until midnight.
Day of: Get up at 6:30am, NO COFFEE, no big projects or significant physical exertion.
Day of: Back to bed at 11am, with the help of a light sleeping aid, a white noise machine, a blackout mask, and the company of a cat who is a good napper.
Day of: Sleep until 4:30 or 5:00pm. COFFEE AT LAST!! Light exercise regimen. Prepare a balanced "breakfast" of high-quality carbs and protein.
Day of: Pack a light lunch and several high-quality snacks. Night shift begins at 7:00pm.

For each night shift:

Pace yourself at night. Work hard but remember to take lunch break at 1:00am or so.
Pack a lunch: the only food available at night at most hospitals is crap, so you want to bring some quality food with you. Right now I'm enjoying a large salad containing a hard-boiled egg and some whole-grain pasta or brown rice. As winter approaches I'm probably going to hot entrees but we'll see.
Carry snacks: otherwise you'll end up eating potato chips and leftover donuts all night long. I like fresh blueberries or another piece of fruit, a handful of pistachio nuts, maybe some peanut butter and graham crackers.
Caffeinate appropriately: I drink lovely coffee from 5:00pm until midnight of a night shift, then no more. If you drink coffee until 7:00am, it is going to be awfully difficult to go to sleep again at 10:00am.
Hydrate: To avoid the horrible, pinched, slightly hung-over feeling night shifts can often produce, I drink plenty of water at night--about two liters, usually lightly flavored with Crystal Light or Propel powder at twice the recommended dilution. I know these drink mixes are nothing but chemicals and damnation, but the sports medicine docs I know cite studies which demonstrate that providing flavored water encourages athletes to drink adequate fluids during competition. (Yes, being a nocturnalist is an endurance event.)
DON'T NAP! If you nap at night, you interrupt the illusion that you're awake during the "day." This doesn't mean you can't take a sanity break, especially between the "siesta" hours of 2:00-4:00am. I usually put my feet up on a chair and close my eyes to listen to some music. However, I do NOT lie down in the call room or permit myself to fall deeply asleep. I've found that napping during night shift makes it harder to sleep during the day, which in turn makes me want to nap at night, etc. etc.
Don't take forever over sign-out: When I'm tired, I start blithering. Furthermore, after working by myself all night, the arrival of the daytime hospitalists feels like being rescued from Gilligan's Island, so I often find myself kibbutzing--but this is a mistake. Sign out in fifteen minutes and go HOME.
Maintain the illusion of night: Before I leave the hospital, I put on dark sunglasses to minimize the amont of daylight my eyes--and therefore my brain--receive on my way home. I keep these shades on until I"m ready to go to bed at 10:00am. This helps induce therapeutic sleep during the day.

After the last night shift:

Return home, give thanks for the end of the ordeal.
Go to bed as soon as you can--8:30 or 9:00am works for me.
Get up again in the early afternoon--not later than 1:30pm.
Caffeinate lightly until the late afternoon.
Stay awake until a normal early bedtime (9:30 or 10:00pm), then go to bed like a normal person.
Be prepared to feel worse the following day, because the day after the day after making a night-to-day transition is the hardest physically. Keep to a standard day schedule but don't take on any detailed projects, such as doing your taxes or putting up curtains.

This method has worked well for me in the past, when I was a Night Float resident, although I've never done 7-8 nights in a row, which is what I'm planning to do as a nocturnalist in the upcoming months.

Rural Career Tip #1

2009-08-21T21:02:33-07:00

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

2009-08-14T10:10:34-07:00

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

2009-08-09T22:03:05-07:00

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.

Among the many surreal, out-of-body moments I had during those four day shifts was one I predicted would happen. I've been a Gimbels outcast for so long, I'm used to being royally snubbed by certain of the specialists who owe their allegiance to Macy's. After I'd made the decision to leave, I dreaded encountering one of these specialists who, after crapping on my head for over four years, might have the almighty gall to pat me on the back and call me by my first name. "My friends call me Theresa," I imagined myself saying with old-school British dignity, "but I would prefer that you call me Dr. Chan."

(Don't worry, I haven't said it yet--but I'm saving it in my arsenal of snappy comebacks. You have my permission to adapt the phrase for use in your own professional disasters.)

Despite my mother and Noo telling me what a paranoid sourpuss I was being, guess what happened? My second day on the job, I met Dr. Foosball in the doctor's lounge. Foos is one of the neurologists who has been giving Gimbels the snub ever since I arrived in Rural. For a while, Foos gave up her privileges there after a rebuke by the Chief of Staff over her failure to show up to a neurologic catastrophe until hours after the first frantic call went out. Her partners covered Gimbels for a couple of years, but then they must have locked her in a closet with a few crusts of bread one weekend, because she recently reapplied and was granted Gimbels privileges again. Not that she ever showed her face around there, but I wasn't yearning for her company anyway.

So after I introduced myself to Foos, her eyes widened and she told me how thrilled she was at my choice to join Macy's staff, how great everyone was in the hospital, what a terrific and supportive relationship she had with all the Hospitalists-R-Us doctors, how much she and her fellow neurologists went out of their way to be helpful to all the other doctors, and how happy she'd be to provide me with any help I needed. Then she went on to explain why she'd resigned privileges at Gimbels, including all the gory details about the neurologic catastrophe which set the ball in motion, and then she made several snarky remarks about Dr. Strangelove, a neurologist in solo practice who has been a Gimbels stalwart for many years. According to Foos, Strangelove is "a difficult person" who "rubs people the wrong way" and "is someone you can never make happy." This about the man who has saved my sorry ass many, many times over the last few years, whom I consider one of my loyal friends and colleagues, and even if he is temperamental at times, I would have him on my tug-of-war team any day over Foos, who is the kind of person who lets go of the rope at the first sight of mud on her shoes. I mean, what kind of person starts trash-talking about a colleague ten minutes after meeting the new staff doctor?

No, I did not say "STEP OFF, BITCH!"--although I've been kicking myself ever since--because I'm the new girl in the playground and I don't want anyone to know about the can of spray paint in my backpack yet. Wait until I start my night shifts later this week, then you'll start to see graffitti on the walls.

The Brave New Hospitalist

2009-07-30T21:16:49-07:00

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.

In my case, the tractor beam on the spaceship plucked me up from Gimbels and dropped me into the wards at Macy's this week. Dr. Smurf was willing to take my place for the swing shifts I was scheduled for this week, and I was sorely tempted to take his offer and stay at home for a few days, but ultimately I decided to get the first day at my old nemesis out of the way. After all, I have a mortgage and student loans to pay for, not to mention Noo and the cats to consider. I would like to be a professional idealist, but it turns out I am merely a breadwinner instead.

So I showed up at Macy's, received my new name badge, dictation number and access codes and was off to the races. Macy's staffs three hospitalists during the day but we work independently, with practically no interaction, so I was at the mercy of the nursing staff to point me in the right direction when I was lost. Which floor am I on? Where is the patient? What am I doing here? What happened to my life? Where is that damn spaceship?

That was the first day. The second was much easier, now that I knew where everything was located and had moderate mastery over Macy's EMR. I have to admit, Macy's has some very rational systems in place. For example, if you order a chest x-ray on a patient in the morning, the order is entered in the EMR, processed by the radiology department, who sends a tech to bring the patient down to X-ray, brings the patient back, scans the image into the EMR, and alerts the radiologist on call, who looks at the image and has a report dictated within an hour. Compare this to the same process at poor old cash-strapped Gimbels, where radiographic images are delivered digitally but dictated onto a different system, and requisitions are processed on paper:

ME: Did 125 get his x-ray this morning?
CHARGE RN: Who?
ME: The guy in 125.
CHARGE RN: Did you check the computer?
ME: The study isn't listed on the computer, which makes me suspect that he didn't get it.
CHARGE RN (calling out to floor RN): Laura, did 125 go to X-ray?
FLOOR RN: X-ray? Was he supposed to get an X-ray today?
ME: Yup. Ordered yesterday afternoon for this morning. Did radiology call for him?
FLOOR RN: Not since I've been here.
CHARGE RN: What about the end of night shift?
FLOOR RN: The night nurse didn't mention the x-ray.
ME (wearily, to Charge RN): Can you find out what's going on?
CHARGE RN: I'll call down.
(Two hours later.)
ME: What happened with that x-ray?
CHARGE RN: Radiology never picked up the requisition yesterday. I found it in the out basket.
ME: O-kay. Do they have it now?
CHARGE RN: I ran it down to them an hour and a half ago?
ME: So did he get the x-ray or not?
CHARGE RN: I've called twice, they say they'll get to him when they can.
ME (with great self-control): So that means the x-ray which I ordered for first thing this morning is going to get done this afternoon?
CHARGE RN: It might.

I wish I were exaggerating, but the above scenario happened to me more than once during my four-plus years at Gimbels.

I've had a number of pleasant moments during these first few days at Macy's. The hospital provides a hot lunch entree in the doctor's lounge, and the medical library actually contains bookshelves with books in them (at Gimbels, the featured item in the library/lounge was a 1984 edition of Current Surgical Diagnosis and Treatment, a real gem of a find on eBay these days). And yet my overall feeling is one of weary detachment, a determination to put my head down and just get the job done, but no excitement, no hopes and dreams for my future there. Things may change after I've been there for a while, but if I see that spaceship again, I'm going to wave it down for a ride out of there.

Everything is (Sort Of) Back to Normal

2009-07-27T10:26:33-07:00

Noo is back home, after several days in Macy's rehab unit, during which she received intensive PT and OT to get her well on her way to recovering lost strength. Our dog is ecstatic--Noo is her Person, if you know what I mean--and I notice the cats carry their tails a bit higher now that our little family is reunited.

Noo herself is incredibly upbeat, euphoric from the nectar of survival. I've noticed this in a lot of patients who have survived a critical illness: they awake from ventilator sedation with a sense of amazement at what has happened to them, especially the fact that they are alive to ask the question at all. Life takes on a profound new significance; every taste, every sound, even the aches and pains of ongoing recovery are gifts from this New Life. It is quite a wonderful experience to witness.

So much suspense and turmoil, followed by so much wonder and gratitude, all played against a backdrop of everyday life. I feel like I've been cast in a Shakespearean romance, shipwrecked, stranded, then rescued by benevolent spirits and indelibly transformed. My mind hasn't settled yet.

If Lost, Please Find

2009-07-14T23:19:04-07:00

Good news: Noo was extubated today and appears to be doing OK from the respiratory standpoint. She might be a tad bit delirious after seven days on the vent, but I give everyone a pass on the day of extubation. It is unrealistic to expect My Dinner With Andre, if you know what I mean.

I am happy and relieved that Noo has improved since the acute onset of this illness, but now I have to face what happens next. Most people are quite debilitated and vulnerable to other problems after a significant hospital stay. For the last week I have been mentally preparing for all kinds of outcomes, and maybe this is why I found myself driving on our rural highway with absolutely no idea which exit to take to meet the Gimbels staff for a farewell dinner. At first I thought I missed the exit, so I got back on the highway heading south, only to realize I had been a couple of miles short of the correct exit in the first place. I had to exit again, loop around to the northbound on-ramp, and--after a few minutes of grim concentration--arrived intact at my intended destination. This is the same highway on which I've been driving back and forth for five years, the same on-ramps and off-ramps, only not the same life. Life seems to have irrevocably changed since the first time I drove on these roads, and my New Mind is as lost as a tourist in these parts.

All I have to say is: Thank God for margaritas and for the pitchers they come in. That's all.