Category Archives: teamwork

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Serendipity

I took this zoom shot of Independence Monument in the Colorado National Monument. I was pretty much blind, but I’ve spend so much time photographing in sunlight on the beach, that I am happy with the composition. I had no idea that I captured the climbers until I looked at it at home.

This is without any zoom.

Zooming closer.

And later along the canyon, we saw the first climber on top. They are both there, but I was shooting blind again.

What an amazing and fabulous day.

For the Ragtag Daily Prompt: off-beat.

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And the wookie?

Our Sunrise Rotary of Port Townsend is selling tickets for the Running of the Balls, 2000 numbered golf balls to roll down Monroe Street before the Rhody Parade on May 18. This is from a few weeks ago. We even had a wookie helping.

Aren’t you jealous?

For the Ragtag Daily Prompt: funky.

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Wise fear

I don’t think the team of four taking down the four trunks of this cedar were fearless. They were sensibly afraid and stopped between each trunk. They discussed the next step and had all the safety gear in place that was possible. It was still very dangerous.

For the Ragtag Daily Prompt: fearless.

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On order

Back in 2002, our private clinic became part of the hospital. The biggest local insurer had quit paying for everyone’s work for 9 months and then was taken over by the state. We were still not getting paid.

One day the employees were very tickled and happy. I cornered the office manager at lunch and asked what was going on.

“We have to use the hospital to order everything,” she said. The nurses and staff at lunch had expectant grins. “We asked them to procure a henway. The order was put in. Yesterday we got a call from someone in the ordering department. She said, “We’ve searched the medical catalogs, but we can’t find it. What’s a henway?” She got transferred a few times and reached the office manager. Reply: “About the same as a rooster.” The clinic staff broke up again. My office manager said, “Well, that person was pretty new, so we hope they’ll get over it.”

I am sure that the hospital loved having us on board.

For the Ragtag Daily Prompt: procure.

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The women don’t see

A man I know is writing about retirement. He says that he has made excuses for years, that he has to travel for work, and not participated with family or entertaining activities.

That work is the only thing he is good at.

I don’t see the problem.

He has four people who have given him accolades for his write up. All men.

The women don’t see the problem.

In college I play soccer. I am not good, but adequate. None of us are really good. We have 12 people. Men and women. I ask a friend to join us.

“No.” he says.

“Why not?” I ask. “You’ve been saying you need exercise.”

“I am not good at it.”

“So what?”

“People expect men to be good at things. You don’t know what it’s like to have that expectation.”

I glare at him. “You don’t know what it’s like to be a woman and have people expect you to be bad at things.”

I knew a veteran. He complained to me about women. “I want a woman who is interested in cars and guns. That’s what I’m interested in.”

“Um,” I say. “Maybe you could develop some other interests? Join a club?”

“No.” he says. “Cars and guns. Why aren’t women interested?”

I am sure that some are. I am also sure that they are expected to know nothing about cars or guns and then are hazed and finally celebrated for being an amazing woman who is interested in cars and guns and has skills and knowledge. How amazing.

The women don’t see the problem with being good at work and not having developed anything else. We often are treated as if we are morons and have a man explain things to us. I have a skill that I have been developing and practicing for decades. Yet a man about 15 years younger than me who is in his first year of practicing, explains it all to me. I look at him and think, you are an idiot. Really. You KNOW I have years and years of experience. I offer to show him another way to do part of it and he soundly rejects and scolds me. “You’ll confuse me! I do it the way I was taught!” I clam up and just think, well, he’s over 30 and still stupid. Bummer. He talks about his amazing development and tells me what he has learned and advises me. Snort. I am ready to take a restroom break the next time he explains what I should be doing. The toilet is more fun than he is.

The women and the single fathers don’t see the problem. If you are raising the kids while working and keeping track of all the stuff: laundry, soccer practice, dentist appointments, helping your 8 year old pick a present for another kid, when is the party and where? Oh, the same day as the parent teacher conferences. Your child may want to do a sport that you know damn-all about or play an instrument that sounds like a rabbit is being strangled or join the young Rotary group. You are not a joiner and view this with an awed horror. But an involved parent will extend themselves into this new unknown alien arena and learn with the child.

And the people who do not have children but are trying to take care of an aging parent or disabled sibling or a long time friend. They too have to learn the systems and the medical one is a deteriorating nightmare labyrinth.

So to say one is good only at work and afraid of retirement: We don’t see it. What are you talking about? We are doing stuff we know nothing about initially as fast as the darn children grow. This month they want their own laptop and are installing linux and “Mom, we need faster wi-fi.” “I am making dinner.” “But mom, the game is timing out.” Huh. Ok, time to call the woman who we know who will explain wi-fi. “Figure out how much it costs, you’ll have to earn part of it if it’s more expensive.” “Mo-ommmm!”

Retirement: begin again. What have you wished to learn, to do, to explore? Be a beginner. Join us. We begin again daily.

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Doctors are leaving medicine

https://www.healthgrades.com/pro/7-reasons-doctors-are-leaving-medicine?CID=64embrdTINL120523

Ok, reason number five: “One study finds doctors spend two hours on EHR record-keeping for every single hour in clinical contact with patients. EHR dissatisfaction has been linked to higher burnout scores, and burnout can lead doctors to leave clinical practice or quit medicine altogether.”

Back in 2009 I argued with my employer about their policy. They had put us all to 20 minute visits, one 40 minute one a day, and continuous visits 8-noon and 1 to 5. Also, they had daily meetings from noon to 1. Full time was four eight hour days, except they are nine hours with the meetings. I said, “Look, one day of clinic generates at least two hours of work: reading lab results, reading radiology reports, calling patients, calling specialists, dealing with insurance, dealing with phone calls, refills, patient requests, calling pharmacies. So four 8 hour clinic days generates another 8 hours minimum of work, plus I have call nights, plus those four hours of meetings every weeks, so I am working 44 hours of week minimum and with call I can hit 60-80 hours in a week.” The administration did not care. I promptly cut to 3.5 patient days. They initially said, “You can only do 3 or 4 days, not 3.5.” I said, “Why?” They said it was not the most efficient use of clinic space. I said, “You don’t have anyone to put in for the full day, so using it for a half day generates more income than having it empty.” They reluctantly agreed.

I could finish a clinic EMR (electronic medical record) note in the room with the patient in 25 minutes but not 20, during the visit. The administration and computer loving doctors had said, this system is to let you finish the note in the room. It took me three years to be able to consistently do that in 25 minutes. Many providers were allowing their home computer to access the system. This meant they were working after hours at home after everyone else was asleep or on weekend morning. I refused to have it at home. I came into clinic at 5 am to do the work, since then I wouldn’t get interrupted, but I wanted home to be home. Also, I live four blocks from that employer.

I decided that I was sticking with finishing the notes in the room. I ran late. I apologized to patients, saying that the hospital was now requiring a quota of 18 patients a day and that I disagreed with it. I tried to convince the administration that I needed more time and help, but they dispensed with me.

Two years later another physician quit medicine and the hospital dropped the quota to 16 patients a day.

So it makes me laugh to see that it says in that article that eight hours of clinic generates sixteen hours of “EMR work”. The implication is often that it is busywork but much of it is NOT busywork. I have to read the xray report and decide what to do with it. Same for every lab. Same for the specialist letter. Same for physical therapy, respiratory therapy, home health, hospice, occupational therapy, notes from psychology or psychiatry, notes from the hospitalization here or elsewhere. Read, decide if I need to do anything, update the EMR? Sign the document off. Decide, decide, decide and get it right. Call the patient or a letter or call a specialist or ask my partner for a second set of brains, am I missing something? This is all WORK.

At one point a clinic shut down in three counties. My clinic (post hospital) took a new patient daily for months. We couldn’t get the notes so we had to look at med lists, get history from the patients and wing it. Or get hospital records labs xrays specialist notes. Yep. Nearly every patient had “deferred maintenance”: they were behind on colonoscopy, mammogram, labs, specialist visit, echocardiogram. We ordered and ordered. Then we had to deal with all the results! After about five months I say to my receptionist, “I’m TIRED.” She was too. We dropped to three new patients a week. Then two. Then one.

I also spent an hour with new patients and my visits were 30 minutes. I was the administrator of my clinic too, and pointed out to the physician (me) that we were not making much money. With 30 minutes I could look at things during the visit and explain results and get much of it, but not all, done.

So if a 20 minute clinic visit generates 40 more minutes of work, in labs, reviewing old records, reading specialist notes, reading about a new medical problem, keeping up on continuing medical education, reading xray reports, echocardiograms, writing letters for jury duty exclusion, sports physicals, disability paperwork, sleep apnea equipment, oxygen equipment, cardiac rehab reports and orders,etc, then how many patients would give us a forty hour week? At one hour per patient, that is 40 patients a week, right? 18 patients daily for 4 days is 72 per week and that is not including the on call or obstetrics done at night and on the weekend. 72 patients would generate another 144 hours of work according to that article which is untenable. 36 hours+144 hours+call = over 180 hours weekly. And so I am not surprised at the levels of burnout and people quitting.

We have to value the actual work of not only “seeing a patient” but “thinking about the patient, reading about a disorder, reading all of the notes and test results and specialist notes”. Isn’t that what we want, someone who will really spend the time and think?

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Work again

I have been wondering whether to try to work again. It’s risky.

I asked the pulmonologist from Swedish Hospital if there was any way to keep from getting pneumonia number five. “We don’t know.” Is it safe for me to return to work? “We don’t know.” I like the plural in the answer, is he speaking for pulmonologists or Swedish or what? Anyhow, the risk is pneumonia number five and death or ending up permanently on oxygen or needing a lung transplant or something stupid like that.

It’s not raining yet and I promised not to even attempt to return to work until it rains.

I saw my cardiologist yesterday. He thinks I should return to work. Early on he said that I am smart, “like one of those old fashioned internists who read everything.” I laughed, because yes, I am a science geek. At the next visit he said, “The family doctors aren’t always as thorough as they could be.” I replied, “I don’t know, after all, I’m a Family Practice Doctor.” “Oh.” he said, “I thought you were an internist.” Which made me laugh because it’s a sort of back handed compliment. Cardiologists do a three year internal medicine training and then more years of sub specialty to become a cardiologist. Most specialists seem to scorn Family Practice a bit, though not all. And I have definitely had specialists ask me for help. A perinatologist: “How do I help people stop smoking?” I laughed at that, too, and replied, “Do you want the five minute , the ten minute, the thirty minute or the one hour lecture?” A med-peds doc asks me to put a cast on a child’s arm because even though she is board certified in internal medicine and pediatrics, she has almost no orthopedic training. I was at that clinic to see obstetric patients that day, but was happy to do the cast too. I love the broad training and the infinite variety of rural Family Practice. It is SO INTERESTING and OFTEN FUN THOUGH NOT ALWAYS. Sometimes it’s sad.

Here is an article about a physician doing what I want to do: https://nymag.com/intelligencer/article/long-covid-treatment-lisa-sanders.html. She thrives on complexity, she thrives on diagnostic puzzles and she writes the column that the television series “House” was based on. When I watched House, what I noticed was the nearly all of the patients on the show were either leaving something out or lying. In reality, I think it’s just that sometimes we need a lot of time to pull together the complex picture and clues. I always pay attention to the pieces of the puzzle that do not fit and sometimes those are the key to finding a diagnosis that is unexpected. Dr. Sanders spends an hour with a new patient. That is what I did in my clinic for the last decade, because that hour gave me so much information and it allows people to feel heard. A ten or fifteen minute visit doesn’t let people speak. It’s slam bam here is your prescription ma’am. What I see in the multitude of notes from all the doctors I’ve seen since 2014 is that they leave most of the conversation out of the note. Things I think are important. I think most of the clinic notes about me are crap and the physician is not listening and doesn’t know what to do. I include the stuff that doesn’t fit and doesn’t seem to make sense in the notes I write. Patient appreciated, when I gave them their note at the end of the visit. “You got all that?” Oh, yes, I tried.

One of the Long Covid symptoms that Dr. Sanders mentions is people “feeling like they are trembling inside.” I’ve seen that before Covid-19. That was a symptom that I did not pin down in a particular patient, but now there is more than one person complaining of the same thing. Really, why don’t physicians include those complaints? It’s egotism to cut out anything you don’t understand and most patients want help so are motivated not to lie. Ok, they might admit that they’ve been out of their blood pressure medicine for two weeks and that’s why their blood pressure is too high, or they’ve been drinking mochas and that’s why their blood sugar is way too high, but they are really in to get help. I think it is a terrible disservice not to document what they say, even if it’s not understood and the physician thinks it’s unrelated to their specialty and they don’t know what to do.

So: I want to do a Long Covid Clinic, with an hour for the first visit, and longer than usual follow ups. Part time because of my lungs and the fatigue. We shall see, right? I am going to look for grants to help set this up.

Think of how much work went in to this statue and this church. The Basilica di San Marco took at least 400 years to build and decorate!

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Tea with a friend

I have a friend over for tea on Thursday.

I make Katy B’s fruit torte, recipe here. Katherine Burling was my maternal grandmother.

The friend worked with me for five years and is surviving lung cancer. She has one of the new treatments. She gets an infusion every three weeks. “For the rest of my life.” she says, but they may come up with something new eventually. She feels pretty terrible after the infusion for a few days.

I use this tea set. I love this set. It says Rose China, Japan, on the bottom. What I like best is that the lid of the teapot has the roof of the pagoda, to line up before I pour. There are six plates, but only three cups and saucers. The sugar bowl and creamer are intact.

For the Ragtag Daily Prompt: tea.

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Shame and anger in overuse illnesses

“amongst those who treat addicts of any kind generally agree that anger and shame help no one and is actively counter-productive.”*

Wait.

I have to think about that statement.

I do not agree at all.

Ok, for the physician/ARNP/PAC, anger at the patient and shaming the patient are not good practice, don’t work, and could make them worse. BUT anger and shame come up.

In many patients.

Sometimes it goes like this with opioid overuse: the person shows up, gets on buprenorphine, and is clean.

It may be a long time since they have been “clean”.

One young man wants to know WHY I am treating him as an opioid overuse patient. “Why are you treating me like an addict?”

I try to be patient. I recommended that he go inpatient, because I don’t think we will cut through the denial outpatient. Very high risk of relapse. “You have been buying oxycodone on the street for more than ten years.”

“I’ve been buying it for back pain, not to party.”

“Did you ever see a doctor about the back pain?”

“Well, no.”

“Buying it illegally is one of the criteria of opiate overuse.”

“But I’m not an addict! I’ve never tried heroin! I have never used needles!”

“We can go through the criteria again.”

He shakes his head.

He is in denial. He is fine. He doesn’t need inpatient. He is super confident, gets work again, is super proud.

And then angry. “My family still won’t talk to me!”

“Um, yes.”

“I’m clean. I’m going to the stupid AA/NA groups! Though I don’t need to. I’m fine!”

“What have you noticed at the groups?”

“What a bunch of liars!” he says, angry. “There are people court ordered there and they are still using! I can tell. They are lying through their teeth!”

“Obvious, huh?”

“Yeah!”

“Did you ever lie while you were taking the oxycodone?”

Now he ducks his head and looks down. “Well, maybe. A little.”

“Do you think your family and friends could tell?”

He glances up at me and away. “Maybe.”

“Your family may be angry and may have trouble trusting you for a while.”

“But I’ve been clean for four months!”

“How many years did you tell untruths?”

“Well.”

Shame and anger. Anger from the family and old friends, who have heard the story before, who are not inclined to trust, who are hurt and sad. The first hurdle is getting clean, but that is only the first one. Repairing relationships takes time and some people may refuse and they have that right! Sometimes patients are shocked that now that they are clean, a relationship can’t be repaired. Or that it may take years to repair. My overuse folks are not exactly used to being patient. And sometimes as they realize how upset the family and friends are, they are very ashamed. And some are very sad, at years lost, and friendships, and loved ones. I have had at least one person disappear, to relapse, after describing introducing someone else to heroin. He died about two years later, in his forties.

Shame and anger definitely come up in overuse illness.

The above is not a single patient, but cobbled together from more than one.

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*from an essay titled “F—ing yes, I’m a fatphobe” on everything2.com. Today there are two with that title. The quotation is from the second essay.