Sunday, February 15, 2015

Early Morning Musings of a Snowbound and Homebound Primary Care Physician

Genmedmom here.

Here in Boston, we've been experiencing winter weather conditions never before seen in modern times. I'm not exaggerating. A series of intense winter storms and an unusually prolonged stretch of extremely cold temperatures have combined to create a Pompeii of snow and ice, rather than ashes. The region is near-paralyzed. Frankly, I'm getting bored of writing about it.

But the fact is, weather disasters unite us, forcing us all to realize that we are weak, small, and, well, only human, compared to Mother Nature.

As a primary care doctor, this weather has also forced me to realize some humbling truths.

One: as a 100% outpatient attending, I am not an "essential worker".

Two: I can do alot of my job over the phone, safely, and with greater patient satisfaction.

For the first two of these last four major winter storms, I was home alone with my two children under five years old. It was not physically possible for me to shovel out in time for work, and I had to cancel some clinic days. For the third, my husband was home, but the weather was so bad that between us, it was still not physically possible to shovel out in time for clinic. I cancelled again. Then, as mass transit was also shut down, and most staff had no reasonable way to travel in, our office ended up closing for a day as well. The hospital announced that basically, only employees essential to inpatient services needed to report to work. The Governor of our state announced that only "essential employees" in general needed to be out on the roads.

All of these weather events equaled alot of patients whose appointments had to be bumped. For all of these days, I reached out to most of my folks directly, and offered to handle their medical issues over the phone to the best of my ability. I felt bad, and so I made myself as available as was reasonable using our secure messaging system, email (many of my patients work at the same hospital) and my cell phone.

Everyone I contacted was thrilled that they didn't have to figure out how to get to my office; most were going to cancel anyways. What I found was that most acute issues were handled safely without a visit; physicals, pap smears were rescheduled.

Examples of issues that were managed successfully included UTIs, candida vaginitis, mild asthma, URIs and sinus infections. I've been following some more complex cases, and we were able to determine stability and plan next steps; these are folks undergoing workups for more serious symptoms.

My internal medicine colleagues described similar scenarios, diagnosing and treating everything from shingles to migraine to flu, over the phone. One of these colleagues commented that "it didn't feel good" when she realized that she was "non-essential".

It wasn't always this way. As a resident, and then a fellow with inpatient responsibilities, calling out for bad weather just wasn't done. Later, as an attending with inpatients to round on, ditto. But our practice has since turned to our hospitalist service to care for our inpatients. This was done with the encouragement of the hospital; almost all practices have done the same. Inpatient medicine is now its own animal.

Still, the idea that I'm an M.D. and also "not essential" feels odd. I feel guilty for staying at home with my kids.

A reader then introduced me to a wonderful doctor-mother blog written by surgeons called: Hot Heels, Cool Kicks, and a Scalpel: Trauma Mamas Balance Fashion, Fitness, and Family. One of their trauma surgeons has also been writing about the snow, and I was so glad to read her posts, as they alleviated my guilt, substantially. Two particularly relevant posts:

Rants of a Snow Beleaguered Trauma Surgeon

A Plea For Snow Days and Common Sense

I am learning to make peace with being non-essential. I am also considering offering telemedicine visits to my patients on a regular basis; though reimbursed at a much lower rate, the patient satisfaction would pay dividends. This may also free up visits for more acute illnesses and/ or physical exams.

My thoughts and prayers go out to the essential healthcare providers and hospital support workers who have to get in to work or stay in the hospital through weather like this, and I would be interested to read more about the experiences from "the other side"....


  1. Zeke Emanuel has talked about outsourcing anesthesiologists and intensivists to Dubai. Maybe primary care will be next.

    1. And radiology is already outsourced, in many places! Yes, just as Minute clinics have popped up and prospered, telemedicine consults with far away Internists are popping up as well... and dermatologists... I have seen these on the web, seen articles written about docs in the US and abroad that offer their clinical opinion, for a fee. I'm not worried about my job, though- Even though I am able to do much of what I do over the phone, it's usually because I know the patient. I rarely see new patients, most of my peeps have been with me for anywhere between 2 and 6 years now. Not ages, I know, but enough to establish a baseline of reliable vs not; as well as what level of instructions they are able to follow. This, and I know I can see them next week in person if needed. This all makes telemedicine consults much easier.

  2. Essential to many, but just not essential at the specific in person location! Your reaching out by phone/messaging seems to have been highly appreciated by your patients. Thanks for writing this post.

    Often I'm helping medical students navigate their transition from student to professionals with responsibilities. Essential adds another layer of complexity that will come to them down the road.

    I'm mildly curious --but not intending to challenge-- if you felt you'd somehow compromised the prescribing you did over the phone that you wouldn't have ordinarily done (a la judicious use of antibiotics, etc). Then again, I don't live in Boston!

    1. Thanks T! Oh yes, definitely erring on the side of caution in a few cases, and not just over the phone. I was in the office on friday, and saw a number of patients who probably had the more benign process going on, but with this blizzard on the way, they did walk out with the prescription (to fill and hold onto, in most cases, with instructions on what to look for before starting) or with imaging/labs ordered that I would have otherwise deferred. Usually I would feel fine to monitor, even over the weekend, because I can delay prescribing or imaging/labs until needed, and send folks to a medical walkin unit if needed. But people weren't going to be able to even leave their homes for at least a 24-hour period, maybe longer (the roads are slippery and mass transit is still not running on full service, even this Monday morning). My elderly, frail patients are having an incredibly tough time in general right now, even if they have VNA services checking in, as the VNA's are quite challenged to get to them, and even if they do, parking can be impossible! It's such a crazy situation we've got here, unprecedented... and other snowstorm on the way for tomorrow night....

    2. Got it (and some snow/ice here now as well). These storms have such a big impact. Be safe and keep doing great work.

  3. You are completely essential: that's not what's at issue here. What's at issue is how you deliver care.

    I'm sure you've read "Escape Fire," the greatest thing written about American medicine since "House of God," but let me quote the relevant passage:

    "The access we need to create is access to help and healing, and that does not always mean—in fact, I think it rarely means—reliance on face-to-face meetings between patients, doctors, and nurses. Tackled well, I believe that
    this new framework will gradually reveal that half or more of our encounters—maybe as many as 80 percent of them—are neither wanted by patients nor deeply believed in by professionals.

    This is an example of a problem so big that we have trouble seeing it. The health care encounter as a face-to-face visit is a dinosaur. More exactly, it is a form of relationship of immense and irreplaceable value to a few of the people we seek to help, and these few have their access severely curtailed by the use of visits to meet the needs of many, whose needs could be better met through other kinds of encounters."

    As trainees, we all had it drilled into us over and over that you have to go and see the patient. You have to do it. That is the delivery of medical care, and anything else is lazy and dangerous.

    I think we get this pounded into us over and over because, if we're being very honest, a lot of the time the very last thing we want to do is walk into a patient's room. And if we are doing medicine from a distance to shield ourselves from the patient encounter, obviously the patients will suffer.

    But we need to get over the knee-jerk reaction. Every day, I make medical decisions based on what nurses and paramedics tell me, without an opportunity to reassess the patient immediately. It has to be done, or people will die in the waiting room as I juggle 20 signout patients instead of tending to new business.

    We need to change our payment models such that all billing for diagnostic and thinking services is not based around the visit. Then we should assess, openly and honestly, who needs to come in and who can be managed another way. In every case, the decision to treat remotely will involve risk and require clinical judgement. If someone is going to be told NOT to come in, who do you want making that call? The physician, that's who. You are more essential under a mixed in-person/remote model, not less.

  4. Genmedmom,
    I just stumbled across this since it was listed as a top referrer to some of my snow-related posts. Thanks so much for sharing. Can you believe it is snowing again?!


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