Sunday, September 26, 2010

Temporary Insanity

Life as a physician is busy. It would be wonderful to have a day to just read: textbooks, journal articles, look up stuff relating to perplexing cases, but that does not happen. It would be nice to come home not completely spent emotionally, physically and mentally and have a second wind to do something else. Not usually on a weekday.

The solution: temporary insanity.

Every so often, I get a complete weekend off -- no call, no volunteer work scheduled, no extra shifts, (we'll not talk about the piled up reading, studying for boards, doing CME activity, it'll be our little secret). This is not often, you understand.

That's when it happens: temporary insanity.

For 2 glorious days, I am not a doctor, not a scientist and sometimes, not even a sentient being. I eat. I sleep. I watch a nonsensical movie. I buy a comicbook or a science fiction mag. I vegetate. It's like a mini-vacation. It's pretending that there are no pending deadlines, it's supressing the perpetual guilt one feels for not studying enough, not reading enough, not being up to date with every last shred of paperwork, not having answered every last email, not having cleaned the bathtub in a while, or the kitchen, or ...never mind. Temporary insanity makes it all go away. It feels good. In the words of a country song I heard "I don't have to be me till Monday."

20 minutes

What does 20 minutes to you? To me, during the work day, it is the length of time I have to spend with my patient who is here for anything but a complete physical. It doesn't matter: cough, cold, diarrhea, feeling suicidal, family crisis, swollen knee that needs fluid taken off, or discussing the test results that reveals a possible malignancy. I often joke about having to solve the world's problems in 20 minutes -- that is primary care. Of course, I exaggerate a little and jest a little, but only a little.

Er... did I mention, I usually run late and work through most lunches? You might wonder what the problem is: why can't we take more time with our patients? The answer is logistic, philosophic and economic and part mystery (to me, anyway). I understand but I don't understand. Ever been there?

One problem is advanced access: the number of days it takes to be able to see your doctor if you call, the first available appointment to establish care, or for follow up or for an acute problem. You could go to the ER or urgent care, but then, why have a doctor if you can never get in to see him or her when you need him/her? The other aspect is economic: primary care is reimbursed not for the amount of time you spent, but for the type of visit (office visit, often called an E & M [evaluation and management] visit) and the number of diagnosis made. These are paid at a much lower rate that a procedure of equivalent time by most payors (the government, insurance companies and such). Consequently, the only way to 'break even' (balance the cost of running a clinic that does primary care) is to see more patients in a given day.

Again, I don't understand it all. It sometimes seems like a factory (with terms like productivity, number of patients seen per unit time or in our world RVUs generated (RVU=revenue value units).

I try to spend as much time as the situation seems to require. I do not look at the clock or 'kick' a needy patient out because their 'time's up'. Consequently, as the day advances, I fall behind and my patients may get a bit flustered because they showed up on time for an appointment and find that they have to wait an extra 20 to 45 minutes.

By the way, there is no allocated time for phone calls, emails, pages, filling out forms or signing prescriptions to be called in. Those are squeezed in as you walk out of one room and before you walk into the next. You also need to document the visit (we dictate our clinical notes) and bill (to register the diagnosis).


It's madness. It's a sisiphial task. It's frustrating. But, I LOVE what I do, I LOVE seeing patients and (hopefully on most days) making a difference and yes, sometimes, on a good day, I do solve the world's problems in the magical 20 minutes. :-)

A mother's worst nightmare

The story has been heard before, but this is the first time I was part of it. I have a young adult girl and her family in my practice. On a Monday morning I got a phone call from her mother that she was raped over the weekend.

Stop here for a moment.

In the middle of a busy Monday morning rush of patients waiting in rooms to be seen, phone calls to be answers, the pager going off and my email inbox warning me that there were several unread messages, time stood still.

Her friend invited her to a party on a Saturday night and introduced her to a boy. One thing led to the next and there she was in the ER. She said 'no' but maybe too late? Although a young adult, she lives with her parents and has some issues with depression and some developmental delay. A rape kit was collected, although it was locked away because she did not want to press charges because "I don't want him to get into trouble". The next day however, she changed her mind and the wheels are set into motion.

We treated her for potential sexually transmitted disease exposure, tested her for pregnancy and set up an appointment for her counselor.

Running behind. My medical assistant reminds me that room 2 is a 1-month old baby boy here for a well child visit with his parents. I put my feelings in the ice box, put a smile on my face and walk in to a happy family.

City on a Hill -- A free medical clinic

Every second Saturday of the month I try to go over to Milwaukee to work at the Free Medical Clinic. This is run by a missionary organization called City on a Hill ( that does wonderful work in inner city Milwaukee. The clinic is held every second Saturday of the month. It runs from noon till about 5 pm. Anyone can come. No money is charged. The photo alongside shows the last of several hundred poeple getting in on a Saturday afternoon in September 2010. Did I mention, there is a free lunch and an opportunity to take home a grocery bags of basic foods?

Most medications are provided with the visit, free of charge. This is an amazing work. There are about 3-5 doctors who volunteer on a regular basis. We have a filing cabinet and each patient has a 'chart'. Vitals are taken by volunteer nurses. There are allied services such as free foot care, smoking cessation, flu shots (in the season) and occassionally optometry and physical therapy.
Diagnosis is an interesting experience. Labs and x-rays are very expensive and not available on site. Most diagnosis therefore relies heavily on history and physical exam (aren't we supposed to be able to diagnose most things that way? ;-) ). I have gotten to hear some interesting aortic stenosis murmurs, perform incision and drainage of a cyst, clean out a cerumen impacted ear using a syringe and an IV catheter and palpate some impressive goiters like this one.
In medical school, I was taught the biopsychosocial model of medicine. I believe in the biopsychosociospiritual model: illnesses can have a spiritual component as well. Poor choices or decisions in life, unforgiveness, bitterness, anxiety, guilt -- where else can you place these in the biopsychosocial model?
Working here once a month teaches me to appreciate what we have. The first time I went, I treated a homeless man for pneumonia and a family for scabies. I could not believe I was in one of major cities in the United States.
We sometimes have premeds and medical students come along and with the patient's permission shadow us while we work. We often have to write out our own labels for the prescriptions, count out the pills and fill the bottles ourselves and then explain the instructions to the patient. It gives one a sense of appreciation for other members of the medical team that we have back in our 'not-free' clinics -- receptionists, medical assistants, nurses and pharmacists to mention a few.
Perhaps the most touching aspect of the work is how grateful the patients are that we come. They say thank you again and again, as if we are the ones that are inconvenienced and suffering. I don't presume to know how to fix our broken healthcare system, but when I see out of work, homeless folk with diabetes, hypertension, skin conditions and other chronic medical problems who must make do with a once a month free clinic with a limited selection of drugs, I know I must do something. So I go.