Family Practice is Dying (and it's not their fault)

This is going to be controversial. I don't want to hurt anybody's feelings, but I do think that this is an issue that should be discussed.

Ok. Time for everybody to face reality. Family medicine as a "specialty" is dying. It's nobody's fault, but it's time to close the residencies and to redirect the medical students into other fields.

I didn't always think this way. I trained with some really amazing family practice docs because my ob/gyn residency also offered a family practice 1 year "c/s fellowship" so that family medicine docs could get cesarean section privileges.

However, what I've seen in the last almost 1 year as an attending at a hospital with a large number of fp docs with both ob and c/s privileges has changed my mind about the entire existence of family practice. Most of these docs, when they practice ob/gyn, don't really know what they're doing. They don't understand that a peripartum cardiomyopathy is a dilated cardiomyopathy. If a patient who had a baby 3 months ago has impaired diastolic relaxation, hypertension, and a low EF, that's not a peripartum cardiomyopathy. That's diastolic heart failure. That's a beta blocker deficiency in many cases. It's related to the patient's underlying severe chronic hypertension, not to their pregnancy.

They think it's appropriate for family practice docs to do complicated cesarean sections. Fourth and fifth repeats. Previas. They fail to refer moms with hemodynamically significant cardiac lesions to perinatology. They fail to offer 17 hydroxyprogesterone, or to send patients for a consultation to evaluate if they're candidates, when these patients have had very preterm deliveries.

There are a few docs who understand obstetrics enough to stay within their scope of care, but most of the family docs at our hospital go far beyond a reasonable family practice scope of care in ob/gyn (which should be limited to normal pregnancies). The problem is, their training in ob is just a few months (ok, maybe 6 months total if they complete the c/s fellowship which includes a lot of other stuff, it's marketed as a rural medicine fellowship). With that little training, they can't hope to have an appreciation for everything that can go wrong. I had over 1000 c/s under my belt before I graduated from residency. I did almost 2000 vaginal deliveries, 200 operative vaginal deliveries (prob about 100 forceps/100 vacuums). For a doc to think that they can do what a general ob gyn can do with about 10-20% as much operative experience is ludicrous. The answer then, would be for family docs who want to do ob/gyn to confine themselves to completely normal obstetrics, and arrange for an ob/gyn backup. The other problem is that there's no good compensation model for this, unless a procedure is required. Even then, in obstetrics, it's usually all about the global fee. So in some cases, the family practice docs risk loosing payment for the entire pregnancy if the patient is delivered by someone else. These global fees can get unbundled, but the person who provided the prenatal care invariably gets the short end of the stick when the fees get unbundled. Not only that, but malpractice costs can often provide a perverse incentive for FPs to practice outside of their scope of practice.

Once a doc's attentions are diverted to their entire practice and they're taking care of men, women, children, pregnant women, etc, maintaining competence within their scope of practice also dictates that they practice a very limited scope of practice. Physician training is so expensive that it may not make economic sense to train a bunch of docs who will then go on to have limited scopes of practice in several different fields. And while a lot of patients don't have complex medical needs (although many do), when you only have very shallow training in multiple fields, how do you know when a pregnant woman is sick? How do you know when a child is sick? It's experience that really allows people to see where the line between ok and not ok is and where you can really intervene and make a difference.

If people really wanted to have a limited practice and do well child checks and sore throats and uncomplicated hypertension and diabetes, that would likely be reaosnable but economically unsustainable. In any case, what I see are family practice residents who want to do procedures. They spend 6 weeks in Dillingham, Alaska doing colonoscopies. They ask if they can come do amniocenteses with me. They want to do my versions and operative deliveries with me. And I have to say "no", because these are procedures family practice docs should not be doing. The risk of complications with amniocentesis is higher with people who are less experienced. Version success rates are higher with more experience. And seriously? No family practice doc will be doing my next colonoscopy. Those are rightly in the hands of gastroenterologists who will be doing the treatment for abnormal findings. I suspect it is a search for higher reimbursement that drives these trainees to attempt to gain competence in procedures outside a reasonable scope of practice.

Now if we lived in a society that valued maintaining wellness as much as treating disease, well, it might be a different story. But even with respect to wellness, I don't think that the family practice docs would be any more effective at helping me loose my prednisone pudge (the almost 90 lbs I gained after 3 years on prednisone). I would be willing to guess that their scores with other types of wellness management would be similar to other primary care types (like internists and pediatricians). I do think that you do need to be able to spend real time with people in order to help them learn how to take care of themselves. Lecturing people about self control for 3 minutes is not helpful. Helping them learn what they can do to positively impact their health is helpful, but it also takes time that nobody in the US (including the patients themselves in many cases) are willing to pay for.

The advantage of the nature of training of family practice docs is that they have (if only brief) exposure to a wide variety of medical circumstances, which means that they may be even better than other primary care types (like internists) at quarterbacking the care of patients with lifelong chronic ilnesses, especially as they negotiate the transition into adulthood. However, this may not require visits, but it requires time in the office and phone calls (neither of which are things that our society cares to compensate doctors for because, you know, can't anybody make a phone call? *sarcasm intentional*).

So, the two natural niches of family practitioners, wellness and quarterbacking the care of patients with multiple medical problems, are not valued by our society at least in any monetary way.

But, attempting to extend their scope of care into procedures that are outside of a reasonable scope of practice for a fp doc will not fix this problem. I learned how to do appies in residency, just like anybody who operates in the pelvis does. However, if I get into trouble with an appendectomy or if I were to start an appendectomy and run into a different surgical problem in the abdomen, well, I just don't have the training for that. So I don't do appies. I leave them to the general surgeons. Doing c/s, colonoscopies, etc in an urban setting is simply deviating from the heart of what family practice is supposed to be. And the problem with doing them in a rural setting is that well, very few of the fp docs I know want to move to a rural setting (although those that do practice in a rural community without easy access to a tertiary care hospital seem to be exceptionally sharp), becuase well, no cable, no DVR, no ballet, no museums, no REI stores, etc.

For the record, a lot of the "scope of practice" stuff wouldn't apply to a rural area. If a patient needs a c/s and the local family doc is the only doc in.. .say... Coldfoot, Alaska I would want that doc to be able to do something. But in an odd coincidence, none of the "rural medicine" fellows are actually headed out to rural medicine. If they were actually going to go do rural medicine, I would have no problem with a more extended scope of practice, because even if they haven't had enough experience to be super skilled, they may still be the best option for many situations.

However, that's not the type of practice most family practice docs are training for. Most family practice residents are training for a practice model that doesn't actually exist in any compensated way.

Under Construction

I'm updating my blog to better serve you!

(just kidding, it's actually because I want to).

First project is the blogroll.... but I am sorry if you don't find yourself over there. I think I have to update it by hand??

Not Dead Yet!

Sorry about the extended absence. I've been reading a lot of your blogs, just not posting much. Why? Maybe not a lot to say, maybe getting used to being an attending (a "real doc", finally). Maybe a lot to do. Mostly, I was finding that time just slipped away from me, with one day melding into another.

When You Know A Bad Doctor

How do you protect people from a bad doctor? Obviously if they're criminally bad, substance abusing, patient abusing, etc. and you are aware of the behavior, you can, and probably should, report them to the local medical board. Many states have ways to facilitate this.

But what do you do when you notice a pattern of practice from a doctor that is just not consistent with good medical care? When a patient who's baby has multiple birth defects is not offered an appropriate or complete workup? When patients are transferred to the hospital in an unsafe manner? When you know a doc is practicing outside their scope of care, or at least not practicing good medicine within their scope of care?

In the community I'm practicing in now, it's not that every other doc is incompetent. There are just a few, but the poor hapless patients end up in their care. And it seems like there's no way to protect them. Bad judgement, poor decisions are not prosecutable, and my area of the country has a low level of malpractice suits. Where I've been previously, these docs would get sued a couple of times and then practice gyn only or family practice without ob. But there's nothing I can do to protect the patients. Patients know when a doc is nice to them, but they have no way of knowing if their doc is a good doc or a bad doc. I can report people for illeagal behavior, but there's no way to report docs for being idiots. Obviously, I wouldn't send my patients to them, but there's a shortage of people doing obstetrics here, so some patients are always going to come to get their care with the Dr. Nincompoops.

This is Amazing

My present to myself for completing my thesis was the new quad core iMac. OMG! I'm in love. I guess I'm going to have to become a mac person now....

It's been too long!

OK, it's been a really long time. Sorry everybody!

In the meanwhile, though, I have finished my fellowship thesis and a couple of papers. For the last 3 months that's taken every ounce of spare energy and time left after work and sleep. Combine that with having caught giardia from the dog (and the colitis flare triggered by the giardia), potty training the dog, walking the dog, etc.

First, the pup-date! Zoe the puppy is doing mostly well. She is now ~60lbs (compared to 14 oz at birth) and is probably 1/2 of her adult size. She's had giardia, gave me giardia, and now has reacquired giardia from me (drinking out of the toilet IS hazardous!). She got spayed a week ago, and she's mostly healed but did manage to separate her incision in 2 places (~1 cm each). She's going to see the vet to see if we need to do anything about it. And she has dysplasia in her heel and may require little doggy arthroscopic surgery for it (or dogoscopy as my friend calls it!). That sounds like a lot of problems, and it has been frustrating because I really just want to play with her and teach her to do tricks and be a good dog and stuff, and she's been benched for most of the past month, but I think we're close to getting stuff resolved and by the end of January, everything should be fine.

Work's been good. Our office has moved into sweet new digs. I finally got all of my stuff framed for my wall so my office will look like a real doctors' office. I'm finally in a place where I can do my work and then actually leave it to go home or to martial arts class or doggy obediance class or whatever. I have to say, life after training IS so much better than fellowship or even residency (although I liked my residency). I think part of this is because I chose to become a private practice doctor. (more on the private practice/academic practice division later).

And, by the way, XE: you should invite me to read your blog! I can't access it right now. :(

Another Pup-Date! :)

Here's Puppies!

Puppies!! Mine is one of the black and white ones, and I think her name is Zoe. :)

Good Doc or Nice Doc

I have now escaped the hospital (actually did it about a week ago). The whole 4.5 days I was there, all I really ever wanted was to go home. And I made no bones about it.

I showed up in the emergency room, and asked the ED doc for some iv fluids and some zofran, and told her that I didn't need any more than that, I didn't think, and that I would just leave. She offered me some narcs, I declined. She offered me a ct scan, I declined, and then she said, "will you at least please stay for some labs and for me to curbside gi on how to get you in to see someone before next februrary?", and I agreed. Then, she walked away, for a bit (she had sick people to see, I think), and came back just a few minutes later, and sort of laid down the law. She said unless I stayed for the abdominal ct (I think it was useless, but the ED scans pretty much everybody with tender bellies), the lab results, 2L of IVF, 2 doses of iv steroids, and a gi consult (she said they would come by at 7am), it would be against medical advice. So, I started to negotiate ("How about 1 dose of the steroids and I'll see the gi doc in a couple of days as an outpatient..."). At some point, the dilaudid started, and every time I tried to get my stuff together to go (or asked my nurse about some discharge papers), they drugged me again. Sneaky bastards. I do have to admit, I was quite uncomfortable, and dilaudid is quite effective for eliminating pain. I wasn't snowed enough to be considered "chemically restrained", but at the same time, you give 1 mg of dilaudid to someone who's essentially opiod naieve, and in addition to relieving them of pain, you will releive them of the motivation to sign out AMA, or really to leave at all.

The night was kind of bad. The ED just isn't a great place to hang out. Between the woman having an MI next to me and the lady yelling at the top of her voice, "bring me more dilaudid you f---ing c-nt!!", it's just not terribly restful, and everything that is annoying is more annoying when you're nauseated and having severe diarrhea. (dilaudid fixes that, too!).

Around 8 am I realized I wasn't going to be able to go home, and even if I convinced them to discharge me or to bring me AMA paperwork, I wasn't going to be able to work safely. I still was getting lightheaded and profusely sweating just walking to the bathroom, so I finally agreed to stay, and they took me to a hospital room. They actually hid me away on the oncology floor in a very tiny but pleasant and private room wiht a view of the ocean. The one good thing about UC is that if you get admitted to the hospital, there's always the possibility you could have C.diff, so you always get a medically necessary private room.

The nurses were extremely sweet to me. One brought in movies and books (that I was too fatigued to watch or read). They were very conscientous, and even went above and beyond the call of duty. In fact, my only complaint about the hospital is that the pillows suck. If I'd realized they were going to talk me into staying, I would have brought my own. For a couple of days, I felt too ill to concentrate on reading or movies, but started to spend more time awake. This is the annoying part of being sick. And I got so bored. I tried going for a walk, but didn't make it very far. Anyway, the nurses and aids would come in and actually chat with me. I felt a little bad about it, because I'm sure that they were busy, but I really appreciated it.

The gastroenterologist was, perhaps, a weirdo. I can't decide if he's a good doc or a bad doc. He sort of tread the line between being condescending and setting limits. Apparently he's the one that suggested the scheduled (as opposed to as needed) dilaudid (and it actually did slow the bathroom trips down a lot) that started in the ED. When he saw me the morning I was admitted, I told him that since I'd tolerated the ct contrast, I could probably go home on some oral steroids the next morning. I told him I really wanted to go to work, that it was a new job, and my first one out of training... blah blah blah. He listened for a little bit, but then stopped me, and said, "If you won't stay for 48 hours of IV steroids and until you're eating 3 meals a day on oral prednisone, then your gut won't heal, and we don't have anything else to talk about. " And he basically threatened to fire me if I left before his conditions were met. Now on one hand, I can see how he was probably right. I was a little anemic and a little dry on admission. On the other hand, well, he really was kind of bossy about it. On the third hand, I hope this doesn't mean that he's going to yell at me all the time as my doctor, 'cause I'm not into that. At the same time, he was, in other ways, very nice. I was explaining that I had been on prednisone for most of the last 2 years, never had a sustained remission, really, and that I'd gained like 40-50lbs on the prednisone. He told me, "Of course you did, almost everybody does, and we'll get you off the prednisone". And he told me a plan. And a plan in case the plan fails. And, aside from being bossy about staying in the hospital, he was pretty nice. And I guess, as a doc, I know that there are times when I just have to put my foot down to my patients, but usually it's about something serious, like the fact that they are putting themselves or their baby at risk of death by leaving the hospital. Not about the merits of inpatient vs outpatient treatment. So now I'm wondering how nice of a guy he'll really be. I mean, maybe he really did think it was vital for me to stay in the hospital? Or is he really a bit of a jerk? Everybody says he's the best guy for inflammatory bowel disease in the northwest, but nobody says he's the nicest guy around. At the same time, if he gets me feeling well consistently and off the prednisone on a long-term or permanent basis (without a colectomy), do I really care if he's a nice guy? I mean, nice is better than mean, but good is better than nice. My UC was, apparently been mismanaged by a pretty nice guy for a while, so maybe I should just be glad that I get to trade nice for good?

The rest of the hospital stay was the same. Too much dilaudid, too much food, which I forced myself to eat so that they would be sure to send me home. And the last week has been pretty good. I was home on Saturday, back to work on Monday, and I'm on call this weekend. The weird thing is? I feel so good now, I think I've probably been sicker for longer than I would have thought, if that makes sense. I haven't felt this good in maybe a year? Even the prednisone side effects, which are annoying (sleeplessness, increased apetite, weight gain, hot flashes), are worth it to feel this good right now.

Doctor as Patient

So, I'm having a somewhat interesting experience right now. I ended up in the hospital. This was only partially my fault.

So, I've posted elsewhere about my ulcerative colitis. Mostly not a problem, except I've gained 40-50lbs on the prednisone I take for it. Or... took for it. So, given the weight gain, and the fact that every time I've gained a few pounds on it, I've been completely unsuccessful at loosing it, and because of the acne, I tapered and stopped my prednisone. 6 weeks ago. It went perfectly fine until 4 weeks ago. And although I'd started to get sick 4 weeks ago, I sort of figured that it might just get better (this really has never happened to me... but hope springs eternal!). And then, Monday, after having slept 40 of 48 hours this weekend, I realized something was really wrong. So I restarted my prednisone and made a gastroenterology appointment. They could get me in in 6 weeks. Um.. yay? So, I tried to keep on keeping on. Then tuesday night, I started having more abdominal pain and vomitting. Not tolerating even fluids orally is probably unsustainable in someone who has copious bloody diarrhea. I'm a doctor, there are some things I know. So after 6 hours of playing the rest for a few minutes, then try to drink, then vomitt, then rest gaime, I decided I'd go to the Emergency Department.

I figured I'd be in for some iv fluids, labs, some iv antiemetics, and then gone in time enough to make it to work on Wednesday morning. In fact, I came in saying, "I don't want to be admitted, I'm here so that I will be able to make it to work tomorrow morning. " I did get some labs, some iv antiemetics, a ct scan which I don't think I needed, and a couple of liters of normal saline (iv fluids) and some potassium. They admitted me, but only after giving me iv dilaudid and then convincing me to let them admit me. I do believe the ED doc, the hospitalist, and the gi on call were plotting against me this way. I feel as though tolerating the oral ct scan contrast was an adequate test of my ability to tolerate po. They say they will let me go tomorrow.

Some interesting observations:
1) the woman next to me in the ED was there for a chf exacerbation and had just eaten a ribeye steak, and had a blood sugar of ~500.
2) Lidocaine really does help when people are putting in IV's, especially those that are 18 gage or larger.
3) I wasn't super sick, but I was the sickest person (not counting the kids waiting for the children's hospital ED) in the waiting room. There were many drunk people and some with complaints that should have been taken care of as an outpatient.
4) I can't get a doctors appt as a new patient for 6+ weeks with a PCP. Faster if I torture myself by using my physician status to sneak in, which I refuse to do. So, maybe if some of the people who use the ED as their PCP could get an appointment with someone they wouldn't be in the ED. Of course, if they had established care when they should have, they would have a PCP by now.
5) Screaming, "You F&*king c*&t" is not a good way to get more pain medicine faster.
5) The hospitalist docs are nice. So are the nurses. So are the gi guys. They seem competent.
6) I think that dietary depts across the country are not designed to work well. I'm ordered for a low residue diet, but still, every day they offer me all sorts of salad and non-low residue things. If I didn't know what I shouldn't be eating (no salads, desserts ad lib, veggies and fruits should be cooked except bananas which are fair game), I would have a hard time.
7) My patients who complain about once or twice daily fragmin can suck it up. It's not that bad, and it's a damn site better than a dvt.
8) Although it feels like a disaster to call in sick to work, it really isn't, esp if you're really sick.
9) Good friends will feed the cats and bring pajamas and computers and movies
10) My siblings are more helpful than I have any right to expect.



More soon....

Time for a Pup-date! :)

Hi Everyone!

Eventually, I will get back to medicine, I promise. Mostly, anyway. OK, well, some. The last couple of months have been kind of crazy, but in a good way. The events go as follows.


Middle of June: Graduation!
End of June: I defended my thesis and took my Maternal-Fetal Medicne boards. :)
End of June-Early July: Moved to west coast... 3000 mile drive with 2 cats and my brother.
Early July: Broke ankle (tiny itsy bitsy medial malleolar fracture) while jogging. I thought it was a sprain until it didn't really get better very quickly.
July 20: Started new job!
Tonight: First night on call for new job. It's amazing how much better this is than being a fellow, already. People care what I think. ?!?!? and I have input into my schedule!!

July 27: Puppy (pictured) born. I wonder how Bardiac knew. ;)

More Soon

In response to Bardiac, and others, I still exist, but got distracted. :) I'll post more soon.

Luck sucks

How is it on my very last call as a fellow I get a blood/body fluid exposure? Ah, well, low risk patient, and a scalpel stab is a pretty low risk exposure, but still.. I went 3 years without one, and now I get stabbed?

What if I don't Want to Multitask?

Multitasking has been a serious fad (or perhaps gone beyond fad status...fadus?) for several years now. And I know I must be some sort of luddites (do luddites blog?), but I DONT WANT to multitask. Seriously.

I want to do one thing at a time, and finish that one thing and go on to the next. I don't want to talk to a nurse at the desk while I talk to the pharmacy on the phone and make a decision about the patient in the next room. I want to do the tasks in the appropriate prioritized order, because in my experience, multitasking leads to less good decision making.

And all of these little gadgets that let you talk on the phone while you drive or do laundry or watch dvds while driving? I actually don't like to talk on the phone while I drive. It's too distracting.

I was told during my internship that the key to being a good intern was multitasking. Well, I've come to disagree. I think the key is prioritizing.

Should I Join the Uninsured?

A little dilemma... my health insurance through my current program will be immediately cancelled on June 30/July 1 at midnight. My COBRA payment would be $450. Clearly, one (even relatively minor) medical problem could cost more than that. I'm sort of strapped for cash these days (moving expenses, and all). I'm unlikely to need anything other than prednisone and the Lialda for my UC (ok, and I take some propranolol for migraine prophylaxis, but that's dirt cheap... so is the prednisone). However, a sprained ankle with an ER visit could cost >$1000.




Seriously, I plan on continuing my insurance. I can, however, see how some people make other decisions. And, outside of employer provided insurance, the ulcerative colitis would make me practically uninsurable.

Just some food for thought....

Homebirths

Because I'm, you know, a high risk obstetrician, people even my friends, often assume that I'm against homebirths. Well, I'm not, exactly.

There certainly are a few disasters that can't be predicted, and may not be able to be treated in time to prevent maternal or fetal injury that we can deal with better in the hospital. But that list is pretty limited to catastrophic abruption, moderate to severe shoulder dystocia and umbilical cord prolapse. Sometimes, with these complications, there is no time to get to the hospital, and the baby and/or mom can die. And, to be honest, sometimes laboring in the room 10 feet from the operating room doesn't help with these either.

The other thing to remember is that these are rare events. Even in hospitals. Even in high risk populations they're uncommon. In fact, they're so uncommon that the statistics for perinatal death for homebirths are not any different (it's like if you have a 1/1000 perinatal mortality/morbidity rate and add to it a rare event, it doesn't increase the risk by very much. Even if you double the risk, that's not a big increase for rare events). And most of the complications of pregnancy and labor are things like arrest of labor or infection, and with those, as long as the midwife in question acts appropriately and gets patients to the hospital, there's time to treat. In fact, a recent Dutch study in BJOG was unable to find a significant increase in perinatal mortality in low risk women.

If you are a high risk woman, you should give birth in the hospital. Mostly because that's where the pediatricians are. Sure, fetal monitoring reduces the risk of neonatal seizures (but not cp) in high risk women, but mostly, infants of diabetic mothers, infants with growth restriction, preterm babies, etc. need to be in the hospital. If you've had a previous c/s, your likelyhood of a catastrophic complication of labor (uterine rupture) is high enough that you should give birth in a hospital, because timely recognition and emergency delivery can be lifesaving for infant and mother. And many, many other complications of pregnancy are best managed in the hospital.

But a normal uncomplicated pregnant woman wants to give birth at home? Sure, go for it! There may even be some (at least hypothetical) benefits to home birth: We have MRSA (that drug resistant staph you hear about on the news) running around our hospitals... if you can avoid exposing your baby to that, that's excellent. But please, if things start to deviate from the normal, please come to the hospital. We'll take good care of you and try to limit what we do to only necessary interventions, but interventions really are sometimes necessary (10% of women used to die in childbirth... and 30% of babies used to die before the age of 1).

As for me, well, if I ever have a baby, I'll do it in the hospital... for a few reasons. Number one, Having seen all of the bad stuff, I'd be too nervous to do it at home. Number two: um... having a baby is REALLY messy. If you deliver in the hospital, someone else cleans up. And number three? one word: EPIDURAL!!! ;)

But... just because I'm a wuss and want pain control and someone else to do the cleaning doesn't mean that everybody has to make the same choices I do. The only thing I worry about with home births is that there are a lot of lay midwives doing them. I've worked with some great CNMs, but lay midwives have no specific training requirements. So, check out your midwife carefully.

Transitions

I'm on call, waiting for a c-section to go. My thesis is written (actually halfway through draft 2), my paper (about the thesis work) is also written, mostly. My presentation for my defense is done. What else to do, but blog?

You know, it's kind of funny. With fellowship winding down (IF they will ever let me defend so I can graduate...), I've been reflecting on the past.

Transitions are always an odd time. I've had plenty of them... you'd think I'd be used to it by now. But I think you never really get used to packing up your life and moving it halfway across the country. One of the weird things about medical training is that you have ~3-4 times you pack up your life and move sort of built into the training.

Anyway, this has me feeling kind of introspective, thinking about this and other transitions. I moved a lot as a kid. By the time I was in 9th grade, I had been in 9 different schools in 7 different cities, spread up to 5000 miles in distance. Thanks, BP! So, again, I should be used to this by now.

So, in some ways, this is like almost any move: Rediculously expensive, stressful (it takes a lot to get things organized to move me+2 cats), etc. But mostly, it's not like my other moves. Just a month into the fellowship here (back in August, 2006), I decided that these people were not very nice (the MFM division, not the patients... there are a few nice attendings, but for the most part, I'm treated worse here than I was as a resident), and that I wouldn't be staying. I flirted with an ICU fellowship and a PhD, but decided not to do them primarily because I don't want to have to be here any more. So, unlike most of my other moves, there's a sense of relief. A sense of "Thank goodness I can drive away on June 28 and it will all be over, and I'll never be under the control of those people ever again."

Also, this time, I have movers who are going to show up on June 27th and pack up all of my crap. I'm looking forward to that being a lot easier than packing it up myself, throwing it in a UHaul and driving it 2600 miles across the country.

However, the rituals of moving, the sorting through my stuff, getting immunization records, tb records, licenses, credentialling is so reminiscent of other transisions, it's just hard not to feel like it's happening again.

It's weird, sort of. My ability to get settled in this fellowship was hampered by the fact that I was still suffering the effects of a terrible incident from residency. Something I've realized wasn't really my fault, even if I was one of the primary 'dramatis personae', as it were. And, so I find myself feeling anxious. Anxious, partly because just the fact that I'm at another turning point in my life is so reminiscent of how terrible I felt the last time in my life I was in this place. And a little anxious because I keep thinking of that... that.. thing. (Although a little known secret... trying to not think about bad stuff doesn't help... but in a weird way, just letting yourself think about it kind of does).

And I'm anxious for all the normal reasons... will my new job be nice? Will people like me there? Will I like the people there?

Having said that, I'm not abnormally anxious, and in general, I'm really looking forward to working wiht and for people who will not (I hope) do things like cancel my defense 4 hours prior to the event, after I've already had to make an emergency call switch because they rescheduled it 4 days prior to the date..and then reschedule it ("with a 95% certainty") for 2 weeks away.

Sorry, another non-medical post. I guess I'm in a more personal mood right now. I'll get over it. Maybe.

(picture credit)

Seriously??

They cancelled my defense so that they could entertain out of town guests. 4 hours prior. ARGH!!!

But thanks for all of the well-wishes everybody.

Whew and Wha????

I just finished the first draft of my thesis (and have a firm defense date, scheduled, May 26th). I realize that the first draft is not going to be the final, and I have a bit of work left to do. It is, however, such a relief to have a (relatively) complete version finished!

And, because I've been doing a lot of "last things" recently, I did my last teaching conference (which we get paid a small amount of money into our 'educational' fund for). So, I went to buy a new laptop with the money. It wasn't a very expensive laptop ($800), just something that's lighter that will get me through until I start my real job (soon!!! Licensing is done, credentialling is almost done). Anyway, BestBuy tried to sell me a $500 extended warrenty. On an $800 laptop! If I had $500 to spend on an extended warrenty, I would just buy a new computer when the new one breaks.

Blogs Need Dogs

Ok, maybe blogs do or do not need dogs, but I really really want a dog, starting with a puppy, and finishing with what the puppy grows up into. I think a Newfoundland would be the PERFECT dog for me.. intelligent, easy to please, sweat disposition... and to do water rescue training with one would be really cool.

I now find myself plotting on how to pick a place to live that will be dog appropriate and how to figure out what to do with the dog when I'm at work.....

If anybody knows any reputable Newf breeders in the pacific northwest, let me know!

Are You Reading My Blog?

(I realize lemurs have nothing to do with this post, but I took this picture and thought these lemurs were adorable!)

I'm in Scotland (most of you already figured that out) at the annual scientific meeting of the SGI (Society for Gynecologic Investigation). Apparently after seeing that maybe I should have been a psychiatrist (on the previous post), they decided to take me up on it.

Today's symposium was on stress and reproductive dysfunction. So, it probably won't surprise anybody to hear that just like people have a range of height, they have a range of susceptibility to stress (as measured by basal cortisol levels). It also turns out that those people who are more stress susceptible are more likely to develop hypothalamic amenorrhea (loosing your periods because your brain stops telling your ovaries to ovulate), which is one of the major causes of infertility. It turns out when you have women with infertilty from hypothalamic amenorrhea (people we used to tell to exercise less and eat more), they get pregnant from CBT (Cognitive Behavioural Therapy). Or.. Rather... they get pregnant from sex, but CBT increases the odds, and restores their menstrual cycles.

And if you have certain stress susceptible monkeys (as defined by biologic assays performed when they're not stressed... they actually have chronically higher levels of cortisol), and you stress them out just a little bit (nothing dangerous... just moving them to a new room, for example), and make them exercise or diet, or expose them to more mild-moderate type stress, they'll get hypothalamic pituitary dysfunction related amenorrhea. And, if you give the monkeys citalopram (hard to do CBT with monkeys, they keep throwing feces at the therapists! ;) ), their cortisol levels normalize and their menstrual periods come back.

And although bedrest for preterm labor doesn't work, we probably feel like it does, because activating the CRH pathways in the maternal brain can activate them in the placenta and fetus... and people who live under chronic psychosocial stress (or who are socioeconomically disadvantaged) are more likely to go into preterm labor. When you put them in the hospital on bedrest, you isolate them from a lot of their previous stress, but when you randomize them to bedrest in hospital vs normal activity in hospital or bedrest at home vs normal activity at home, you won't see a difference.

The question then is, how do you talk to people about the fact that they're "stress susceptible" without making it sound like you're telling them that they're wusses? In fact, every time my mom says, "I think your ulcerative colitis is from stress" (Although certain forms of stress (certain aspects of work politics, not sleeping, etc.) make it worse, it is an immunologic/genetic condition) I feel like she's calling me a wuss. It's hard to refer someone for psychotherapy to treat their infertility without the patient getting the perception that you think there's something wrong with her... which, you probably do (you know, the infertility she came seeking treatment for), but not like she thinks (you (probably) don't think she's crazy, unless she wants you to transfer 6 embryos, in which case she DEFINATELY is crazy). Which, I guess is more a social stigma issue than a medical issue... although social stigma IS a medical issue. Becaue medically, I think the best I can do is to say, "We know that people with this type of infertility respond well to psychotherapy/antidepressants/nap time/whatever, and that's definately less invasive than IVF/ovulation induction, so I think we should try that first." I think you also have to have a psychotherapist that sort of expects these patients to come to them from you.

If that makes any sense....

I should have been a psychiatrist?

OB/gyn is down there at #26 or so, and perinatologist isn't on the list (it may not be one of the specialties on the test).

#1-10 in order were:

psychiatry (I'm not sure I really like talking to people this much)
general surgery (almost did a gen surg residency at one point)
occupational med (no way!)
ortho (ok... it always looked fun)
GI (erm... ok..)
colorectal surgeon (kinda like gen surg, so ok..)
urology (ok.. I could see this procedure oriented patient care specialty)
preventative medicine (is this really a specialty?)
radiology (not that fond of dark rooms, actually)
neurology (Um... I like for my patients to get better, thanks. Not that good with diseases that don't go away.)

I'm not sure how I answered the questions wrong, but it seems like there isn't even a consistent theme in my results. Try it yourself at: http://www.med-ed.virginia.edu/specialties/

I remain convinced that the real way to choose a medical specialty is to try out different stuff until you find something you love. There really is something for everybody from radiologists to psychiatrists, from preventative med (still not sure if that's a real specialty) to perinatology. But I'm not convinced this quiz will help you find it.

Thank God Someone Speaks American Around Here!

So, I actually made it to the meeting today, kind of. Long story short, I thought today was the 19th, and I'd signed up for some of the courses on the 19th (I didn't pay for any of the postgraduate courses, you know, the kind that cost $200+ for a single day of class). Anyway, I've gotten back into jogging (was out of it for 2 months because of a bad ankle sprain), but maybe overdid it a tiny bit (Glasgow's hilly! The midwest is not!), and have been a bit sore (esp in the iliotibial band type area). Mostly I just tell myself to suck it up because pain builds character (or whatever), but found myself feeling grumpy, so I decided to buy some acetomenophen/tylenol.

Stopped into a pharmacy (apparently all drugs are behind the counter here), asked for acetomenophen and tylenol (trying to think... now what else is this stuff called?), and the lady behind the counter was looking confused (but wanted to help). Someone yelled from the back, "That's American for Paracetamol!"

Hah! I was afraid I was going to have to ask for "something for sore legs" and see what they offered....

Seriously?

A sunburn? In Scotland? In MARCH??

WTF. I usually wear sunscreen every day (because I burn pretty easily and have lost most of the skin on my face and back and back of my legs at one point or another to blistering sunburns. Always surprised they don't scar). I forgot to bring it with me, and figured... "eh... it's March, it'll be ok", and now after a day out in moderately sunny weather, I'm feeling that post outing mild-sunburn warmth and redness in my cheeks and across my nose.

Note to self: buy sunscreen!

Thank you, Trooper

I'm doing a lot of traveling right now. I was out on the west coast earlier this weekend, and now I'm here, in Amsterdam, headed to Scotland. Lots of work to do, too. On Friday night, it all caught up with me. I was driving back to my hotel (nearish to the airport) from my mom's house (150 miles from the airport). I had given 2 hours of lectures at a conference, and hopped into my car to go visit my mom, who lives... well... 150 miles north of the conference venue.

Add the cumulative exhaustion of 11 years of medical training to the traveling and the conference giving, and well, I was exhausted. But my mom has had a rough time, and she needs to feel like people care, I think. So, I went to see her. My plan was to go, get there and leave by 630-7pm. I got there, she and my aunt wanted to go for appetizers, but they really kidnapped me into a full dinner. (Remind me to get better at setting limits with and saying no to them.), so it was 9-10pm by the time I was leaving town. I started the trip out tired, and I remember at one point thinking about whether or not I was too tired to make it down to the hotel, or if I should pull off and get some coffee or something and rest for afew minutes. Well, that would have been good, but before I could make that decision, I saw the police lights in back. At first I thought it couldn't have been me, because I was driving well below the speed limit...

They were after me. The officer said that I was changing lanes and braking erratically (How embarassing is it to be pulled over for suspected drunk driving only to be sober?). I didn't really remember that. After talking to the state trooper, I must have been driving pretty badly. I think I fell asleep while driving. He didn't ticket me, and the adrenaline from the traffic stop pretty much woke me up to get the rest of the way to the hotel (~15 miles).

In retrospect, he may have saved my life (or more importantly, kept me from killing some poor innocent people). I really appreciate that. Next time, I need to have the guts to tell my mom that I'm too tired to drive 300 miles round-trip. And in the future, when I feel that tired and sleepy, I will pull over before putting anybody else at risk.

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A Submarine... With Donuts?

Greetings from Shiphol Airport, Amsterdam, where I am sitting, during a 4 hour layover, on my way to Scotland. It's a very circle-ey place. It reminds me a bit of a submarine... with donuts. :)

On Healthcare Reform

(My VBAC post is getting written, but I just have a few minutes, and this post only takes a few minutes).

To me, it seems very wrong that our office pays $260 for an interpreter for 45 minutes to see a patient. It's wrong because the visit which I just saw the patient for is probably non-reimbursable, and if it's reimbursable at all, the reimbursment will be <$100.

I actually don't think it's a bad idea for docs to see patients for free... but who can afford to donate their time plus $150-$260 for any real fraction of their patient population. These things aren't tax deductable, yet we're madated to meet the needs of people who can't speak and understand English. Why is it the docs are required to donate their time and money while the sign interpreter donates nothing?

I can see why private practice docs don't see patients like this. If I were in a real private practice, I too might be forced to tell these patients that they should go to the local university hospital because I would be unable to meet their needs (unable to meet their needs and still pay my staff, that is).

If people are serious about healthcare reform, this is a problem they should tackle.

On Service

I've been a bad bad blogger. You know, work, etc. Now, I'm awake at 3am because of night sweat/fever induced insomnia and I find myself actually hoping I'm catching a cold. Because the other likely alternative is that the colitis is back after months of pretty good control on 10mg of prednisone (which induces its own insomnia, but one that's treatable with sleep hygeine and Ambien (tm) and more or less mild at this dose). And I often will have a flare when I work a lot of hours, and I've been working from 6am-8pm most days of the week this month (except when I'm on call in which case it's usually like 6am-2pm the next day)

Anyway, in response to Bardiac's question, being on service means being the fellow in charge of the MFM inpatient service and outpatient clinics. Generally, we also work with a group of residents (my residents are awesome!) as well as a supervising attending. Most attendings will let me have the autonomy to manage the patients how I want (within the standard of care), however, I'm stuck with an extremely anxious attending for the inpatients who freaks out all the time and yells at the residents (which is at least better than her yelling at me?), and so I make a lot of effort to anticipate what she would want to do and plan to do things that way (a month-long game of "guess what I'm thinking") so that she doesn't feel threatened or nervous and freak out and yell at them (or me... but mostly she yells at them). I know, I don't have to do that, but I really HATE it when people yell.

The other attending is a brand new attending (so new that she will be taking her board exams with me in a few months) and she doesn't trust anything anybody does. Including me. So, every time someone presents a chart to her, she hunts through it to make sure that there's nothing else. Probably good patient care, but #1: She can trust me, and it doesn't feel good when she doesn't (and micromanagement is bad leadership) and #2: it's not good patient care to cause such long delays... patients walk out without being seen.

So, because we have to round early enough to get everything done before clinic, we start at 5:30am-6:30am, which makes for really long days, because the residents will then have stuff to finish up on the inpatient service after the clinics end at 6pm. I think this is not compliant with their work-hours, because they also take call on the weekend, so my guess is that they work ~100 hours a week with only a couple of days off. I worry that after being yelled at (by attending a) and not trusted (by attending b), they will not like MFM, and that would be a shame, because perinatology is fun. And because, ultimately, we need a steady supply of perinatologists to replace people who leave (retire, etc). And scaring otherwise good residents away is not a good strategy for the continuation of our medical species.

The residents, however, are troopers, and are taking the yelling from a and the micromanagement from b in good graces. And now we're all halfway done with the month. Hurray!

So, anyway, being "on service" means being responsible for the care and feeding of 2-4 residents (for me, 3) , a variable number of medical students (right now 0, because they don't want to do the month with these attendings... wise choice), and responsible for making plans for high-risk pregnant patients. It's usually a good month, but right now, it's complicated. And at least it's half-way done.

Just Passing Through

I've been in San Diego for a conference for a week (end of Jan), and I'm headed to Scotland next month for another conference.

I'm on service for the next 3 months (and last 3 months of service of my fellowship! Yay!).

More soon.... I can't decide if I should post about resident work hours, the care and feeding of interns, or some more obstetric topic (vbacs, etc.). I don't plan to talk much about the octuplets except to say that that woman's infertility doc should be beaten with a wet noodle.

I'm a Tool (or 5.5 Months Until Graduation)

So, the program that I'm at primarily regards its fellows as tools... Tools to get vaginal swabbing done. Tools to help with the call schedule. Tools to do the resident education for obstetrical topics, etc.

Our education is such a low priority that there has not been an MFM fellows' lecture series. It's such a low priority that when there are interesting grand rounds or speakers, the attendings will often expect us to cover their resident protected time or clinical activities so that they can go. I try to give them a little slack, because they only have 3 MFMs (for 5700 deliveries and an ultrasound unit).

Our education is such a low priority at this institution that I'm essentially a self-taught MFM.

It's kind of a malignant place, in a lot of ways. They've totally broken the educational social contract of graduate medical education. You know, the understood bit about us helping out the department and attendings at a very low rate of pay (~$46k if you want to know) in exchange for education? Our educational needs/wants are dismissed under the guise of "Learn to be an independant life-long learner!". We can get called in on no notice for a 10 minute meeting on a Saturday that has no identifiable purpose other than to prove that we had a meeting.

Having said this, the most recent event takes the cake. It is no surprise that we are required to defend our thesis prior to graduation. Ok... whatever.

But imagine my surprise when I get an email one night that says basically, 'Your defense is in a week' (apparently that was a convienient time for the attendings). So, I spend 24 hours in a near-panic, until I get an email that says "Oh, never mind, it's in May....".

Now, I just need to manage not to quit for long enough to graduate!

You know, the people here seem to think I'm a disappointment because I didn't choose to go into academic medicine. Had my experience here been better, I might have stayed in academics.

In all fairness, the department has deteriorated to this level likely as a result of the demoralization and burnout of the few remaining attendings. I don't feel that this is an excuse for creating an environment uncondusive to learning, but it is probably the main factor.

For all of you looking at training programs right now, my advice is this: STAY AWAY from programs that don't have enough attendings to do the work!!

More Later

Happy New Year and Happy Holidays everybody (whichever holidays they are, I hope they're happy!).

I just wanted to say I'm not gone, or rather... I'll be back. I have my fellowship thesis defense in a week, so I'm drowning right now.

Wish me luck?

BRRRR!

I'm trying to work up the energy/courage to go outside and jog, but the windchill out there is 2 F right now, so it's difficult! I would just skip, except it's Sunday, which is one of the easiest days for me to find the time to exercise!




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Obstetric Psychiatry and Ethics?

For the first time ever, today I had to seek legal appointment of a guardian for a patient who couldn't make decisions for herself. We commonly consult our psychiatry friends with a question that goes something like, "This lady seems really not right, she wants to [leave AMA, refuse surgery, whatever], could you come make sure she's competent to make that decision." when patients seem like they're impaired and making poor decisions (although oddly (or not) we don't tend to question when they make good decisions).

Generally, the psychiatrists' answers go something like, "Well, she does have a history of [insert garden variety mental illness here], but she isn't too impaired to make her own decisions. And everybody has the right to make bad decisions." Which is true. I had every right to leave the ambulance AMA a couple of years ago. I had a skull fracture, it was a bad decision. But it was my bad decision to make. And you could argue that someone with a recent (say 20 minutes old) head injury with loss of consciousness may not be competent to make their own decisions. And I'm still glad they didn't make me go to the hospital.

So, we had a patient today with a history of conversion disorder (diagnosed after diagnosis of her present pregnancy after a long hospitalization), who actually now is sick with severe preeclampsia/toxemia. She needs to have her baby, but having had 5 previous c-sections, she needs a c-section to deliver.

So, she tried to leave AMA, but stayed for a psych eval. The psychiatrist said that she's not competent, suggested some haldol, and wrote a diagnosis which I can't read (typical doctors' handwriting! ;) ), but I think said something about psychosis, which makes sense, because at times, this patient seems almost delusional (thinks we can read her mind and forcast the past (I know, doesn't make sense to me either).

So, a couple of thoughts. First of all, it's got to be totally scary if your brain doesn't work right, and you have a really dangerous complication of pregnancy and are facing delivery at 30 weeks.

Second, I'm going to go deliver her baby tomorrow. During this admission, but before she seemed delusional, she signed for a tubal ligation. My medical recommendation would be that as this is her 6th c-section, she should have her tubes tied. Should we tie her tubes?

Thirdly, do you tell her she's been deemed incompetent? When I was there, we were skirting around the issues, and managed to get her calmed down enough to give her treatment for a few things (her blood pressure, monitor her baby, treat her headache, and give her the haldol the psychiatrist suggested (and some ambien is planned tonight because she hasn't slept in the 5 days she's been at the hospital. That might cause some psychosis in even the non-mentally ill, I might think!).

(Ethics consult/court signature for her mother's role as guardian/etc. is all taking place nowish.)

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This Blog Has Been Temporarily Interrupted

Blogging has been temporarily interrupted by the purchase of Call of Duty: World at War. Blogging will resume when the Japanese surrender.....