This is the residue of a castle from the 1100s.
For the Ragtag Daily Prompt residue.
This is the residue of a castle from the 1100s.
For the Ragtag Daily Prompt residue.
The Ragtag Daily Prompt today is perpetuity. Trees have a different time sense then we do. They send electrical messages like we do, but they are slower. Still, the tree can change it’s leaves within hours, to taste bad or poison a pest. I wonder if we seem fast and short lived and impatient to them.
Here is my friend Simon Lynge’s Perpetual Now:
My parents’ time warp Beatnik household, 1978, before I went to be an exchange student in Denmark.
We had a German exchange student living with us. She had been placed with a couple with no children, a military family, and was unhappy. My parents agreed that she could move in with us for the rest of her year. I decided to apply as an exchange student. I have not heard from her in years. Blessings, where ever she is.
My sister in 2005, watching while our daughters play in the slip and slide.
We visited both of my paternal aunts and uncle in Virginia in the last few days. The picture is one of my aunts and my daughter.
I also took a picture of these photographs.
My father is in the center, with my two aunts, taken at different dates. The one of my father is in 1938 or 39. Aunt Pat is the same one who is with my daughter.
For Wordless Wednesday.
For the Ragtag Daily Prompt #52: time.
More sage then thyme here. It’s pineapple sage and it loves my garden….
I see patients from 8:30 or 8:00 am until 2:00 pm.
We have people say, “You are off after 2:00.”
Well, no. Most days I work for 2-3 hours beyond the patient contact time. Sometimes I come in early and sometimes it is from 2pm to 5pm and sometimes it is the weekend or into the evening.
So what am I doing?
My goals are to give excellent care AND to work 40 hours a week. Half of my patients are over 65 and many are complicated, with multiple chronic illnesses. When I saw patients 4 days a week for 8 hours, with an hour hospital clinic meeting every day, I also spent at least an additional 8 hours and more trying to keep up with most of those things above. The average family practice physician makes more money than I do. But they also report working 60-70 hours a week on average. I do not think this is good for patients or doctors or doctors’ families or their spouses or children. The primary care burn out report rose from 40% to 50% of the doctors surveyed.
We need change, we need it now, and we need to be realistic about how much work is healthy.
When I was still delivering babies, women would ask if I could guarantee doing the delivery. I would explain: “We do call for up to 72 hours. If you go into labor at the end of that, you would rather have a physician who is awake and rested and has good judgement. Besides, I’m a bit grumpy after 72 hours. ” And they agreed that they really don’t want an exhausted burned out physician.
I took the photograph of Mordechai, our skeleton, today. She is genuine plastic. I wish she would do some of the paperwork, but at least she lightens things by making us laugh. She gets various wigs and outfits and sometimes comes out to show a patient a hip joint.
I am NOT attracted to paperwork. I think I am repelled. For the Daily Prompt: magnetic.
I took this at the Jefferson County Farmer’s Market in Port Townsend this Saturday with my phone. A gorgeous day and a live band. Who was playing? A band with Crow in the name….
I am submitting this to Mundane Monday #119.
January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.
Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….
Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.
So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.
A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.
I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.
Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.
If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.
If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.
Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65
We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.
And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.
https://www.uspreventiveservicestaskforce.org/
guidelines: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
http://jamanetwork.com/journals/jama/fullarticle/1791497
Here is the two page hypertension JNC 8 algorithm: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House: https://www.guideline.gov/
This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..
I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….
NEW FLOWERY JOURNEYS
life, faith, adultimatums.
The flight of tomorrow
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Rural doctor, mom, writes poems, dance, sing.
𝖠𝗇𝗈𝗍𝗁𝖾𝗋 𝖶𝗈𝗋𝖽𝖯𝗋𝖾𝗌𝗌.𝖼𝗈𝗆 𝗌𝗂𝗍𝖾.
Taking the camera for a walk!!!
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