Family Medicine part 2

I like family medicine. I have a good practice with pretty darn good co-workers for the most part. I am liked and respected for the most part by my colleagues. I have patients who really like me and I've seen some who don't care for me one bit. I have my own standards and can stick to them. If I don't want to prescribe XYZ, then I don't have to. I am getting great experience and exposure to myriad conditions and pathologies. I actually get a paid lunch hour to eat and complete admin tasks. I only have to drive 15 minutes to work now instead of an hour. My pay is a little low, I have to work a night or weekend here or there and I have to take call without compensation. My stress is very low now. I have a great MA now. I have actually saved patient's lives. I like family medicine.

Family Medicine

OK, its been a while. It seems I start all my posts this way. I am busy with work and family so sue me. I now work in family medicine. It's been nearly 5 years since I graduated PA school. A few things I've come to learn, Number one: Patient's don't listen. Or they listen but do they do not process what they just heard. Well, most of them don't. A few will do exactly as I ask of them and they tend to do fine. Some hear chest cold and leave thinking pneumonia. Many patients come in wanting, no expecting, a certain treatment based no past experience. The last Dr. I saw gave me Augmentin and I felt fine in 5 days, I want augmentin again. They don't listen to what I have found during their exam and why I think they have xyz. Mostly because Dr. Google or a friend told them they have ABC. They stop taking their antibiotics once they are feeling better, saving the remainder for a rainy day, despite out talk about antibiotic resistance. They don't agree with the diagnosis - they want to have something nasty so they can take antibiotics for a week or week two not knowing what antibiotics are even used to treat. Or, in the case of the ubiqutous head and chest cold, if they aren't healthy in a week, they are back in my office expecting an instant cure, something they imagine I have been keeping on a special shelf, for only the worst cases and most important patients. This is despite the warning that I gave them initially that it may take 2-6 weeks to get back to normal, but as long as they aren't getting worse, they be fine eventually. They come in with 9/10 right lower quadrant abdominal pain, anorexia, nausea, vomiting and diarrhea and wince and moan when I palpate their belly. I tell them I think they could have appendicitis, and explain why I think this is the case and the need to obtain more diagnostics to determine if this is true. I explain that, while I can't look into their abdomen, their history and physical have me concerned enough that I want to get a CT. I have my staff drop everything to schedule the CT for today, and ask the radiology unit to call me on my cell phone with the results, whenever they come back. I send the patient off with direction and instructions for the upcoming scan and explain to them that while it could be many other conditions, this could be a life threatening condition and that we may have to admit them if the CT shows something serious. They leave the clinic armed with verbal and printed information and instructions for their pending diagnostics. I spend the next few hours slightly worried, curious as to their condition and diagnosis. The next couple of hours after that, I consider the reasons why I haven't yet gotten a call from the radiologist. Surely the CT is done by now. I get a call just before bed. It is the radiology tech. She informs me that my patient never showed for their scan. I spend the next few days trying to follow-up with the patient, but their phone goes unanswered. I send a certified letter asking them to follow-up as we had discussed. No reply is ever received. Then a 3 weeks later I see a notice on the EMR. It indicates a patient of mine is in the ER. I open to see that my patient, the one I had worked so hard to get a rapid and accurate diagnosis, has been worked up and will be sent emergently to the OR for a ruptured appendix. The same appendix that I suspected was causing a problem 3 weeks earlier.

In the groove

It's been a while, a long while since I last wrote anything. I wasn't really feeling it and felt I had said most everything I wanted to say. Days blend into days and months ooze on by. My new job is going well. There are always changes - providers leave for greener pastures, staffing cuts are inflicted and efficiencies are scrutinized. I am seeing 20-30 patients a day and really feel like I know what I am doing. That's not to say I know everything. But I ask questions when I need to and trust my instincts. I can assess back or shoulder injury quickly and correctly and can sew a finger tip and nail back on like that. I can run through an exhaustive and complete physical in under 10 minutes. I still make mistakes but I make sure they are small ones and that they only occur once. I learn from other's knowledge and mistakes and try to make their experience mine to the extent possible. I continue to learn from my patients and take pride when they ask for over the physicians I work with. I am humbled when I overhear my supervising physician tell a patient or employer that I am just as capable and skilled as she is in handling their injury or concern. I am fatigued, annoyed and reinforced when support staff bypass other provider, including senior physicians, to ask a question. I get pissed when I hold others to my own standards - I have given them and myself some room within these standards and this has made my day go much smoother. I am really happy to read the comments on this blog knowing that someone, somewhere has taken away something positive from all of this. In terms of being a PA, I am in the groove and I feel good about that.

Stay healthy

A reader of this blog has developed a great way to get healthy and stay motivated. I think it's a great resource. Check it out at: slimkicker.com

-P-

Sent from my iPhone

The past few months...

...have been without much to note for me. The community I work suffered a horrible tragedy in the theater shooting. Strangely, we seem to have missed only a few beats and are predictably normal ways. The fires have mercifully subsided and given way to snow of late. I am still busy at work. Folks can't seem to help but get hurt at work. Friday is always the busiest and last Friday was no exception. I had three new injuries walk in 30 minutes before close. One fellow fell from a ladder 16 ft onto concrete. Another had a hernia for which he already sought treatment in the ED. The last sustained a concussion and had an interesting, albeit not unheard of presentation. His mechanism of injury didn't match his complaints but I still sent him to the ED for urgent imaging. I find myself questioning my patient's motives frequently. Perhaps they want a few days off from work. Maybe they want to get back at there boss or employer for some perceived or real injustice perpetrated against them. Often they have some pathological need for attention. Some feel this is there best chance at a big payday. Most of my patients are honest and recover as expected. There are some that I know, after their first visit, that they will not get better any time soon. We'll see how Friday's patients shake out.

Life

My home state is on fire. Colorado is burning, homes reduced to ash, the sky filled with gray stinging smoke. People are looting burned out homes. Tens of thousands of people have been forced from their homes, due to these infernos, some of which may have been intentionally set. My family and I haven't been directly effected other than not being able to go outside at times due to the smoke. Politicians have started their latest round of attacks on each other. It seems like I am the one they are attacking at times. They certainly spend more time appeasing single issue voters and fighting each other than they do taking care of the country. The healthcare system, my livelihood remains in flux. The world around us, our neighbors and distant countries suffer in violence and hate. Innocent people in this country go without, or worse, are forced into needless suffering by those in a position to help. Today we celebrate the independence of this great country. The greatest liberties known in the history of mankind are held close to our hearts here. But I feel we are not finished with OUR work. Rather than a masterpiece to be held in highest esteem however, our grand republic is simply a work in progress. WE are not done with the work started centuries ago. There are problems. They punch us in the face nearly every day, challenging us to step up and do something. But I am just a simple, middle-aged family man. Smart but not brilliant; relatively fit but fat and tired. My obligations are so consuming, yet so seemingly trivial. But I can do something to keep MY amazing country on the tracks laid by our fore-fathers. Maybe you can too. Whatever you do, do it well. Keep your interactions with others positive. Perhaps if our leaders and we followed one simple but profound piece of advice, we wouldn't have to work (fight) so hard to keep this country between the gutters. Granted we won't find a cure for cancer or build great industry by following this mantra, but I am convinced these and others will come easier if we all simply lived and worked by first Do(ing) No Harm.

New job

I just finished the second week on the new job. My time so far has consisted of training with some patients here and there. The clinic I work in sees occupational medicine patients primarily but we also see urgent care patients as well. This is abig deal for me and I am very happy to have any chance to practice an expanded scope of medicine. I am truly excited to have three day weekends for the forseeable future. That is huge benefit and worth at least $10k per year to me. I am amazed that I work 40-43 hours per week without call, have been out of school for less than 2 years and now make six figures before any bonus! I realize this is not the rule but rather a significant exception. When I interviewed for a family medicine job a couple months ago they wanted me to take call and work 50 hours a week for $75k. I never went into this for the money to be honest, but I am so happy it seems to coming for me anyway. Occ med is seen by many as the dregs of medicine and I have felt that way at times. I would love be in the hospital rounding and patients and managing grave illnesses. But the reality is that what I do is very important although no one will make a medical drama about it. I heal people so that they can work and earn a living and keep they economy running. Not glamorous. There is a shit ton of BS at times. But you know what, there is BS with EVERY specialty I can think of. So, my job is not ideal and will be complaining about on this blog, I know it. But, there are a lot of really good things about it too.

I guess it's a good thing they are mad?

I have been getting the cold shoulder from the higher ups in my small company. Those folks who use to come by and ask me how I am doing and toss around some small talk can only be bothered to say hello to me now. Nothing more. Not a "sad to see you go" or ' i wish you luck in your future endeavors." This wouldn't 'bother' me except these folks have publicly wished the same for every other employee who has left since I started there. I guess it's a good thing they are mad I am leaving rather than being all cheerful and upbeat. Even though I gave them the notice they requested in their employee handbook and have gotten pretty darn good reviews, I don't think I would ever be welcomed back.

My last day in this clinic is 5/10. I am moving to a job much closer to home that will allow me to work 4 10-hour shifts and will pay me $14k/year more to do it. I will still be doing Occ med but will also be doing urgent care as well and the possibility of seeing peds and the flu has me giddy. Well, i guess i'll have to wait on the flu. by the way, did anyone catch the flu this season? I heard so little about it I thought we might have found a cure. So much has happened in the clinic lately that I felt it was time to get out. front office staff turnover is bad. If they do stay they are not terribly great. a new office manager means that all the processes that kept my going smooth flew out the window. Referrals aren't getting placed in a timely fashion and patient care is starting to suffer. Patient's complain to me that the ladies up front are rude and don't answer the phone or return phone calls. I have seen a patient for a month and not have a single referral placed. I ask for the same things over and over, but I still get sub-par work from them. I have let the higher-ups know of these problems but my concerns went mostly unanswered. At best answered but ineffectively. So now I going to work with a big company with lots of resources and talent. I'll be working in a very urban environment as opposed to a semi-rural environment now. I hope things go well there - i think they will. Wife has been pushing for a new home so it looks like we will be getting a new home. It will of course be much larger and twice the cost of home now. The homes where we live now aren't that great in terms of quality and size until you get close to $500k. God i wish we didn't have to spend that much. Looks like we will though. I must get some space of my own to play the drums or paint - I've done neither in more than a year.

It has been a while

I feel that I am maturing as a PA. I recognize and pain over my shortcomings. I try hard to correct them and bemoan my failures. Right now i am working very hard to be fake. Let me explain. My personality and approach is to tell it like it is. If you ask me what I think I will tell you what I think. I will give you an honest and straightforward reply. Some of my patients like this. But many do not. I find that my SP, while she may feel the same about any given patient as I do and often does, she sugar coats everything. She is very, very friendly with every patient, even those that were caught in lies, are faking injuries or are simply not very good people. While I am never rude, I rarely ask the malingering, lying, and rude patients how their holidays were and I certainly won't chat with them about their personal life if it doesn't pertain to their treatment. She will go out her way to be nice to a patient that she feels is, in her own words, a "piece of shit.". I know what you are thinking. How dare he call another human being a piece of shit?! Just who does he think he is after all? I get it. It is not right to think this way. But from time to time we do and for pretty good reasons. Back to my point. Why waste the energy to go out of one's way to be extra nice to someone who, by most accounts is simply gaming the system and doesn't deserve it? It just makes the day easier if you do, that's why. A spoon full of honey helps the medicine go down damn it. These patients make less of a fuss and waste less of your time with BS if they *think* you like them and believe them. to call them on their shit only makes them work harder to convince you -to bring up glaring inconsistencies in their story only forces them to act out a grander tale. Being honest hurts these people and causes them to spill their pain onto all they deal with. So now I realize this. I realize that being this way is not in my genetic makeup. I realize that the days are getting difficult. I realize I need to find a way to make them go by a little smoother. I realize I need to try harder.

Lies, lies,lies

I had a patient today, who admittedly has some serious but old spinal problems, tell me he is almost out of his pain meds that were prescribed by another provider a week ago.  " I maybe have 2 days of meds left" he tells me. This fella had seen me for his initial visit and subsequent visit  but then his claim was denied. So he had to go to the ER for his pain meds. I had to dig but he fessed up to going to the ED on several occasions while his worker's comp claim was adjudicated to get pain meds for his train wreck of a neck. So, since he told about all the visits I had dug up and investigated so I gave him an Rx for #60 oxycodone and put him on a narc contract.  He new what it was before I even mentioned it.  He signs it and went off to fill the Rx. I get a call from the pharmacist telling me that this fine gentleman just had an Rx filled 2 days ago for #120 oxycodone.  I told the pharmacist to rip up my Rx and to tell the patient I asked to do so.  The patient just called as I type this telling me he went back and counted all of his pills and he 68 left and that the pharmacist is wrong and that he got the Rx filled 4 days ago.  These are the kind of patients that make me question what I am doing.  I am sure it isn't as bad as I feel it is, but it seems so many of patients don't want to get better.  It seems so many of them lie.  Shit, I wish I didn't care but I do.

Love my co-workers

The doc I work with just moved a new injury to my schedule from her's so she could purchase holiday decorations for her office.

One of the things I do at work is perform dept of transportation physicals. With a healthy patient this goes smoothly and takes 10 minutes. I had one the other day that took 30 minutes. Keep in mind that truck drivers in general have poor health. They spend all day seated with almost no physical activity. When they stop driving for the day they eat whatever is available at the truck stop. These choices are almost never healthy. In their free time many have been known to undertake risky behaviors. They also are never at home and so they do not see a healthcare professional unless it is urgent These are not just stereotypes. When I worked in health insurance all but one of the companies I worked for refused to underwrite policies for over the road truck drivers. Flat out. No consideration, no negotiations.

So back to my 30 min DOT physical. This guy in his 50's comes in having been on Xanax for 20 years. His psychiatrist is weaning him off of if by putting him on another benzodiazepine. Since he stopped taking Xanax his blood pressure has shot up to 170s / 110s. This blood pressure is incompatible with driving commercial vehicles in the US. Furthermore, taking benzos on a daily basis is also - they are too sedating. Now he's been driving for 20+ years while taking Xanax daily. I certainly never saw him before but this apparently never concerned any of the examiners who cleared him medically in the past. So, now it is up to me to tell this guy that I can't pass him. Now he can get these forms filled out by his specialist providers stating that, in their professional opinion he is not at risk and the medications he is taking won't make him take a nap at the wheel. If he does and comes back with a slightly lower blood pressure I can give a three month card. Well he proceeds to complain that I am taking away his livelyhood and then starts calling everyone he knows. But he won't leave my office. He calls his daughter who works in healthcare and she tells him to go somewhere else and not tell them about his medications and conditions. He calls his employer and complains to them. They run through every scenario; when will he get his Rx for his BP filled? How long can he drive on his current card? Who's going to pay his bills? Why won't I accept some 8 word note he brought in from his PCP stating he is under his care? Then he tries to call everyone of his providers to get them to talk to me so I will sign off on his med certain card. Only it's ten to five so he can't get ahold of them. He complains how I am taking away his livelihood by not clearing him and that all he wants to do is drive his truck and make a living. I explain to him that I want to continue to make a living as a PA and that if he were to wreck his truck i could loose my PA license. He turns to me and asks:"what's a PA"?

Becoming a PA doesn't change your life

Today things seem to have caught up with me all at once.  Nothing really significant if taken separately.  But their cumulative effects have me feeling worn out today.  Work just isn't fun.  It's not miserable, as it had been a couple months ago - it just isn't enjoyable.  I find myself filled with dread when I see certain patients on my schedule. I feel drained by my patients at times - almost never energized by them. The computers are slow and my boss isn't great. Since I work with women I have very little socializing to do - I don't care about cute tops or the size of my butt. I spend 2 hours a day commuting which would be more tolerable if I were commuting to something I looked forward to doing. Plus, with my glass half empty right now I see that time as lost - I would rather have an extra hour a day so I could ride my bike or paint or something.  As it turns out I almost no time for myself now. Between commuting and work, 12 waking hours are accounted for 5 days a week.  When I get home my son is there asking which game or toy we should play with before and after dinner.  After playing with my son I put him to bed, which with reading stories and brushing teeth and whatnot, takes me to 8:30. By then my wife is well into another episode "Housewives of XYZ" - she likewise has similar feelings of time poorly spent and needs to unwind in a way that works for her. I really cannot stand to watch these shows so I usually stay upstairs and read email or facebook or play games on my ipad for an hour or two and go to sleep.

On the upside I have a car to get me to a good paying job where have to do nothing more than think most of the time. I have a beautiful son who wants to spend all the time he can with me. I have plenty of food to eat and a decent house to live in. I have an ipad for goodness' sake. In the whole scheme of things, my problems seem pretty trivial and I am sure there are literally tens of millions of people who might like to be in my shoes. However, these are the problems I face and they do bother me. The thing that bothers me the most is feeling like I am in a rut or that I am on autopilot all the time. I continue for ways to break the cycle.  I long for exercise and activity and creativity.  I search for ways to get these things back.  In the meantime I vent to strangers. 

Got me an iPad!

My lovely wife got me an iPad for our anniversary. Pretty cool, huh? For what I do now, I really don't need much else. I just need to figure out. How to get my Microsoft documents on here so I can edit them and email the out. By the way I got her a necklace from me & ro. My son is doing well and looking to wrap up his second week of kindergarten.

Work is going fine. Recently I saw an amputated distal index finger, a bunch of lacerations, a fractured great toe, a completely torn ankle, a couple hot water burns to the eye, a few dental injuries, and some miscellaneous fractures. This is on top of the multiple rotator cuff strains and tears, carpel tunnel, and a ton of low back injuries. Just a reminder...never twist and lift, never reach out and stoop while pulling or lifting heavy weights and use your knees!

I got one!

I had a patient who came in last week with a very sore, very firm calf after running to respond to an emergency earlier in the day.  No injury really, just pain after resting a bit that was worsening to 10/10 and a lot of swelling.  Other than the swelling he looked fine really and was handling 10/10 pain like a champ.  Well. I sent him to the ED because I had concerns for compartment syndrome.  Turns out he had a major case of compartment syndrome and had an emergency fasciotomy the same day!  He has second surgery to remove 2 fist sized blood clots the next day. He came in today for follow-up with his mom and wife and they were all so grateful for my help. Well needless to say the works of thanks lift up my soul today and the fact that I caught a gravely serious condition gave me a boost of confidence.  

A challenge around every corner

I have worked for a lot of companies and had many bosses.  A few were stellar, most mediocre, and a couple were just plain bad.  Without going into detail things are less than cozy between my boss and I.  Mostly along the lines of - I am the doctor and you are not - kind of crap. I like my job and my patients are, for the most part, great to work with.  It would be nice to get some training, but as it stands, I have had none since I started seeing patients.  No feedback on care or charts or anything.  

I know, this comes off as me complaining again.  Life is rough at times, I know this as well as anyone, believe me.  Maybe I don't write enough about about the highs.  Well, here goes.  My wife and I are working on things and it seems to be going better.  My son is awesome and at five is reading, riding his bike w/o training wheels and swimming, albeit at very much a beginner's pace.  He is a Star Wars fanatic and asks me constantly about the nuances of all the story lines and the scope of power of a Jedi versus the Hulk, for example.  He has a great imagination and loves to draw - much like me at that age.  I will follow his lead and return to art earnestly now that my schedule is under control.

Happy 4th!

Arrrrgh!

My computer is still out of service. Maybe I'll just buy a new one. Thank goodness for the iPhone!

I just had an interesting talk w my SP. I had anpatoent the other day with a pretty obvious MCL tear, probably grade 2. Before he came to me he had been to the ED and had spoken to his supervisor and both told him he NEEDED an MRI and probably surgery. Through my training I know that regardless of what an MRI might show, the treatment for a torn MCL or a sprained MCL is the same. The almost never need surgery and almost always heal on their own. I explained this him as well as the need to reduce the effusion in his knee before an MRI should be obtained. I thought I had his buy in on the treatment plan. Well he called later that day to cancel his PT and follow up here for a second opinion elsewhere. I was informed By my SP that his employer wanted an MRI stat and that in most cases if the employer is willing to take the hit on their workers comp insurance they can have whatever studies they want, even if all medical guidelines indicate otherwise. So now I have been told by my SP to ignore my training and provide whatever studies this employer wants even if it isn't warranted. I feel like a burger king employee again - you can have it your way.

And the beat goes on...

Still posting from my iPhone as my computer sits awaiting an attempt at repair. Still seeing a ton of ortho and neuro. Had a pt with a focal infarction only effecting his occulomotor nerve for his left eye as the result of CO poisoning. Reattached a partially amputated finger in office. Long stretches of the mundane punctuated by some cool shit. I seem be working late every night while my SP does not. If I don't have a question for her I may not even talk to her on a given day. I seem to be doing well though my 90 day review. I even bonused recently...a whole $10! Overall I am happy with the job. I realize there will be difficult or annoying people anywhere and that no place is truly perfect. I like being able to pay my bills and have some money left over. I like being mostly on my own at work.

My beautiful boy turns 5 soon and I am amazed at how great he is. I will mourn the day I am no longer cool in his eyes and have come to appreciate his constant requests to play light sabers or cars. Looking back I cannot remember my dad playing with me. I am working hard to make sure my son won't have the same non-memories when he is older.

PA school was so tough yet it seems like a distant memory now. How is it I can remember getting a string of cellophane-wrapped lollypops from the German couple who lived next door to us in Berlin when I was 2 so clearly, yet trying to recall any particular day in PA brings back only whirls and blurs? I wish I saw my classmates more. We went through it together and only they can relate to that experience and those I have now at work. Sometimes I wish life wasn't so much about moving on.

Computer...is......dead

My computer died so I have held off posting anything. It has been too long so I am taking a break from work to use my iPhone to post. I am pretty busy at work and am essentially on my own unless I have a question. I have gotten really positive feedback from my supervising physician and patients. I can now get through a full physical exam in ten minutes. I have seen some interesting things and some even more interesting patients. My personal life continues to be a roller coaster with more flats and up hill pushes than enjoyable twists and turns. I was hoping my wife would be happier with me being employed and well paid. It seems she continues to find fault with me, our house, our stuff and our lack things and activities that meet her standards. Will a new house make her happy? Will our son's admission to a good kindergarten make her happy? More vacations? A new job? A cleaner house without clutter? Newer diets? Better exercise plans? Going vegetarian? Losing 40 pounds. Will Having a husband who only wants to do/watch/eat what she likes to help her to be happier? At least I can pay a lot of our bills now!