Showing posts with label primary care. Show all posts
Showing posts with label primary care. Show all posts

Monday, April 20, 2015

Hurtling toward the next phase


I have searched but I cannot find the flying trapeze story I read a few years ago that explains my life, so I’ll paraphrase and add to it here:

I swing back and forth preparing for my next take off. I have prepared, but I know that this leap is longer and more challenging than ever before. In spite of a long line of successful jumps, there have been some near-misses, some full on misses, some blood, scrapes and even some still healing deeper wounds. This time I jump, my husband is watching and waiting readying himself for his jump into dissertation land and as we prepare Zo waits by ready to take off with us.

Well MiM friends, it’s official, I have accepted a position as a Pediatrician in my dream clinic. I’ll be back in DC working at an academic center-affiliated community clinic. I did my community pediatrics rotation there as a medical student and so many of my respected supervisors and medical school friends are still there.

Interviews were a whirlwind. I met so many nice people, got lost countless times, learned even more about what I need, want, and will compromise on.  

And now onto school finding. Every day I have a mini-freak out when I think about Little Zo starting pre-k. Our cherubic toddler has been replaced by an almost 4 year old hilariously funny and extremely sweet rib-protruding knock-kneed ball of energy. And then I freak out more about making pick up and drop off work and I pray so intensely that we find the right environment for him and that we will find balance so I can rock my boards and O can finish his dissertation expeditiously. I wish I could transplant his daycare to DC.

And house hunting on a single income in a very tight housing market is not my favorite thing to do but I guess house hunting without the beloved Property Brothers will always be lackluster. We have several leads on promising houses and are heading up next weekend prepared to make an offer. Can’t wait to have our first home secured and then on to do-it-yourself projects for years to come.

This jump seems epic. Push-pull-push-pull, forward backward forward backward, take off.


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"....






Wednesday, July 23, 2014

Say What?!? Time to find a job!

It’s that time of the year. Career preparation time. I am applying for community pediatric jobs in the D-M-V (Washington DC-Virginia-Maryland) area and it feels surreal. Medical school in the area was extremely enjoyable and our family hopes to return and lay some roots (is it weird to really want to be on House Hunters?!?).

What didn’t happen:
- I didn’t get Chief Resident. I was pretty bummed out for several weeks, but I think it’s for the best. My mentors reminded me that I pretty much have all of the skills I would have been able to obtain (leadership, administrative) and if I am totally honest with myself acting as an Inpatient Attending for several weeks and crazy hours is not my cup-of-tea! I’m all about outpatient medicine and am ready to have regular hours, my own patients, and more time with my family. No pseudo-residency-with- poor pay increase for me.

What has happened:
- started talking to my Academic Advisors about my interests in community pediatrics
- had a few outstanding people offer to serve as references (Clinic Director, Chair of our Peds Heme-Onc Department, Mentor, etc . . .)
- written and revised my cover letter
- written and revised my Curriculum Vitae (CV)
- gotten considerable feedback from my Clinic Director, Academic Advisor, family and friends including an amazing sorority sister who's a Lawyer who cut my cover letter up so much that I basically rewrote it and it's soo much better
- started regularly visiting the PracticeLink and Pedsjobs websites
- registered for the AAP National Conference in San Diego in October

What I still have to do:
- finish reading “Lean In” (loving this book, so enlightening and inspiring. I’m all about leaning in!)
- send out my cover letter and CV to personal contacts in the area letting them know I’m ready to “discuss employment opportunities” (loving the sound of that)
- actually find some jobs to apply to
- go to the AAP Conference’s career fair and professional development sessions and dazzle some program/practice reps and learn about interviewing and contracts
- finish the last 11 months of residency
- start work as a Pediatric Attending Physician (woo-hoo!)

Alright practicing physicians - any suggestions? Anything you see missing in my list above? In applying for jobs after Residency what mistakes did you make? What do you wish you’d done differently?

Friday, March 28, 2014

Jack Of All Trades, Master Of None

(Patient accounts have been altered so as to protect their privacy and identity)

When I walked into my internal medicine practice office yesterday morning at 6:30 a.m., I was surprised to see only three patients on my schedule. Then I remembered there was a major winter storm forecast, and no one was sure how bad we were going to get hit. By the time the early administrative staff was arriving at 7:30 a.m., patients had realized the storm was basically just alot of wind, and they started calling. And booking. The 8 a.m. slot filled, then the 8:20, soon all the rest... I had an almost-full schedule in no time. And it was almost all "urgent care".

I love urgent care. It's so nice to take a break from the "comprehensive annual exam". Or at least, the way I approach those... I tend to obsess over missing something, and so I take the annual exam as an opportunity to comb through the patient's chart, and attempt to make appropriate note of every past, present, and possible future health issue. Plus, this is my big chance to catch up with folks on their Real Lives. So, What do you do when you're not sitting on my exam table in a johnny? Of course, folks come in with their own agendas, the lists of questions jotted down on the backs of envelopes or in the iPhone. Some docs shut all that down, citing "This is your preventive health time only!" which is ridiculous. So, the issues are addressed. Then there's the vaccines review, and lab ordering... These may or may not be straightforward, and more often than not involve additional discussion. My physical exams always run overtime.

So, a day of mostly urgent visits, those single-issue problem visits that can be serious, but at least, straightforward, are a welcome change.

On the other hand, these days highlight what is beautiful, difficult, and terrifying about primary care specialties like internal medicine:

1. You're supposed to know everything about everything.

2. Because we're trained to be always thinking about the Whole Patient- Nothing is ever straightforward.


First patient. The check in sheet states "Cough". Ha, easy. Well, not so much. The cough was undertreated asthma in the setting of a mild cold. But his blood pressure was very elevated. And a quick perusal of the chart showed, this was someone who hadn't been in for a couple of years. Turns out this was someone who had extreme doctor anxiety and alot of issues that needed more fine-tuning. So the visit turned into counseling and negotiations. I set up a followup appointment with the actual primary care and sent my note... Hoping the guy comes back.

Now, running fifteen minutes behind, next patient. "Rash". This is only easy if it's Shingles... and it was. But, the patient is a healthcare provider. And they wanted to know- needed to know- know all the occupational health issues around Shingles. Did they need to notify all the patients they had seen in the past day? How long did they need to be out of work? Did my recommendation around that differ from our hospital's occupational health policy? I wanted to be able to provide a modicum of accurate counseling in all of these areas. I spent some time with her researching the guidelines and then asked her to contact both her supervisor and occupational health for the rest. Then she needed a note. We wrestled over how to phrase it. I hit "print". The printer wouldn't print. Had to run to another computer. Time ticking away.

Then done with that, I had to check my clinical messages (our in-office messaging, where the secretaries and nurses send me anything from patient phone or email queries, VNA concerns, controlled substance medication requests, or abnormal lab or radiology results). I need to quickly scan the list and make sure there is nothing requiring urgent attention. Then deal with those. Someone emailed about their ankle sprain. Nurse: They just want X-rays ordered. Can we do that? Me: Not really, please have them make an appointment. Et cetera.

Then, my email. There's several more emails for me in a now-massive email chain regarding one patient of mine. She has a large team of specialists; her case is complicated; she may need to be admitted, and I would need to arrange that. I read quickly and make sure no one has asked me to do anything yet. I know the specialists probably roll their eyes at my questions. I haven't treated many cases of what she has. I have to read up every time she has labs. But she comes to me, and I'm doing the best I can.

Now hopelessly behind. Next patient: STD screening. Ha, easy! Not. Upon questioning, she tells me one of her partners is a recovering IV drug user. I deliver alot of counseling around this, do a pelvic exam with cultures, send for bloodwork and arrange more followup with bloodwork in two months.

Next: Elderly patient with shortness of breath. She was pretty sick. She told me she had almost passed out in the waiting room. Long and short of it, this person was too sick for my office. But, she resisted my emergency room suggestion. We went into negotiations. I called the emergency room to expedite. We waited for a wheelchair. I typed up my assessment and impression so the emergency docs would have it. Why take the time to chart, when the next patient is waiting? I felt like I needed to present at least a reasonable hypothesis for her condition, as well as defend my decision to send her to the emergency room. I delved more into her chart. Why do her lungs sound like a freight train screeching to a halt? Asthma in someone who's never had asthma? COPD is someone who's never smoked? Pneumonia more likely. Pulmonary edema, maybe.... Type it up. Hit "finalize."

Next: Wrist pain in a guy who does martial arts. I had to do a quick review of the possibilities. Refresh myself on the exam findings in occult scaphoid fracture. Then look up what type of immobilizing brace to prescribe while that is being ruled out. Then the printer didn't work again.

Next: Lovely lady with- finally! A very straightforward issue. Simple. I took care of it and was ready to wrap it up, when, she wanted my opinion on the new blood thinners. She's on Coumadin for atrial fibrillation, for stroke prevention. These new blood thinners are advertised on T.V. The cardiologists are prescribing them right and left. I have never prescribed these. I look it up, with her right there, and review some of the major pros and cons. There's no testing to see if someone is on too low or too high of a dose. That's nice. But, they aren't as readily reversible, so if someone has a car accident or a bleeding ulcer, they may bleed to death more easily than otherwise. Basically, that's what I told her, adding that we can also ask her cardiologist about it. No, she said, I like to know my numbers.

Next, next and next. There was a physical exam in there, and a few more not-so-straightforward urgent care visits. That was it. Nine Patients, and a barrage of clinical messages and emails. I was starving, and I had to pee. I peed, ate something at my desk, and delved into charting, billing, and all the messages/ emails, as well as the arrangements to be made for that very sick patient. I checked in with the emergency room on the lady I had sent in- she was to be admitted. Ha. I knew she was sick.

Mixed in there, I check in with home. I'm thinking about my kids. On my personal email, there are messages back and forth about our autistic son who's had some issues at his special education preschool. School aversion, we don't know why. It's getting better, with a good and patient teacher. But, I worry I'm not doing enough reading and research on autism, that we're not doing enough behavioral work at home. So I got on Amazon and researched, ordered some books.

At the end of the day, I wonder why I'm so fried.

Is it a good, or a bad thing, to be in a job where your mind has to hop, skip and jump and WORK from case to case and even within a case? We see everything and anything, and we're expected to counsel on even more. That, plus the balance with home life, taking care of a family...

Is it a good thing to be a Jack of all trades, Master of none?

-posted by Genmedmom (generallymedicine.com)