Not such a tame world....

Continuing down memory lane....

From yesterday. After looking through all the paper bits and scraps I had kept, I ended up with a few piles. [I'm a "pile-r" genetically. I get it from my Dad.] As I examined each patient sticker and my notes, I forced myself to commit it to one of the piles:

1. "Must Write" - this was the collection that with just a few details, I could clearly remember the patient. See their face. Re-live the situation. On a couple, I even had the heart pounding, lump-in-throat sensation all over again. So obviously, these were the patients that even now -- had really meant something to me. Because of my visceral response, these are the ones who really need their stories told.
2. "Stupid Stuff" - This pile evolved when I started to see a pattern that was best described as "Stupid Stuff That Kids Do". This further got broken down into "Bad Luck", "Bad Judgement", and what I like to refer to as the "Crap Shoot" category.
3. "Interesting" - This was the pile that ended up with the unique patients. Like the one & only kid I saw who really had Menke's Disease. These were mostly the oddities, or interesting milestones, like my first "Champagne Tap". I think they were kind of cool -- but the rest of the world out there, maybe not-so-much. Regardless, I couldn't bring myself to trash these notes. So they became pile #3.
4. & 5. were variation on the theme of "volume". I had kept all my pager & call flow-sheets from my senior resident calls. So these notes were filled with tons of admits for diarrhea, dehydration, RSV, asthma, etc. All the basic routine reasons that kids go into the hospital. Ultimately, this ended up being the biggest stack -- but I couldn't bring myself to trash this either. So it went back into the 2 gallon ziploc bag.
5. more volume, even less interesting
6. "Kuddos" - this was the very, very, very small stack of four pieces of paper that were "Atta-boys" or bits of positive reinforcement from three years of residency. I know I have a few others squirrelled away somewhere. But in general, praise was very far & few between in residency.... ["That which doesn't kill us, makes us stronger...."]

What I found very illuminating after this exercise was this:

• All together, I probably have at least 25 interesting patient stories to write. In someways, that's more than I thought there would be.
• I also am bemused by what I didn't find.

I started my search through reams of paper today, intent on finding one particular patient's information. Which I never did find. And as I looked and sorted and consolidated tonight, I'm remembering a few other stories and patients, and I still haven't found their notes. Which means they either fell victim to an earlier purge -- or I have more stuff squirreled away that I'll find in the future.

Regardless, it's been an interesting process going back through this stuff. I think I've finally recovered enough from the trauma of residency to cope. Time has blunted my responses enough, that mentally - I don't get "stuck" back in that time.

It turns out that I've grown-up enough as an attending, that I am very comfortable knowing what I know, knowing what I don't know, and knowing how to manage the rest. So I don't feel haunted by all the insecurities that went along with residency.

I already know that it's going to take awhile to get all of this written. It doesn't help that as I work on one story, that triggers memories of others. And we all know my strong tendency to chase down rabbit holes....

Have patience and check back soon....

I tend to be a "here & now" kind-of-girl....

But Tuesday found me re-living my not-so-distant past of medical education & residency. [Relatively speaking....I graduated from medical school in 1999.] 

For the past week I had a strong urge to focus on my writing. I realized that I hadn't blogged in about two weeks, even though I had had some ideas. It was just that time wasn't easily available.

I'm one of those people that when I undertake a project, I tend to hyper-focus all of my attention on the project, until I get it done [or mostly done...  <sigh>]. There are pluses & minuses to this approach. The biggest minus is that I tend to not start until I know that I have a dedicated block of time. And if there's been one thing I've really discovered after motherhood, it's that uninterrupted time is a rarity. Which means I have a lot of projects that I haven't even really started....

So especially when it comes to my thought process and "flow" for writing, I prefer to write when I'm by myself and the house is quiet. [Again a rarity!] This means either when Tab is at school, or late at night when everyone else is sleeping/occupied. So schedule-wise lately, with the snow/ice days, Tab's posse of 1/2 a dozen kids at the house, my clinic schedule, pets underfoot, etc - I really haven't had a chance to hear myself think.

So this Tuesday was a gift.

I got Tab to school, got a large Coke Zero from Sonic, and returned to my desk at home.With nothing on the agenda until 3pm, I used my time to revisit my paper stacks from residency.

Some background:

During residency, every procedure that I performed had to be documented ad infinitum. So knowing this as a medical student, I started keeping track of what I saw, what I did, what I learned, the mistakes I witnessed.... I was a habitual paper pack-rat, noting my observations about medical education the entire time I was going through the process.

By the time I got done with four years of medical school, a year of general internship, and then three years of residency; I had accumulated a huge amount of paper. Since that final graduation, I have schlepped every bit of it, all over the state of Texas. Interestingly [and this is one of many reasons I maintain I had PTSD from residency....] I would know the papers were piled up, but I couldn't get rid of them. And I couldn't get myself to sort or purge them either. So they remained stashed in a file box in the garage, a set of binders in a dining room buffet, and overflowing out of a drawer in my office.

The first great purge probably happened about 2005. Although volume-wise I don't think I actually threw away much. But just the fact that I could let go of anything was a victory.  Then about 2007, I decided that I really wanted that office drawer for something else -- probably scrapbook related. So I managed to trash a bit more. In 2009, I actually went through the whole collection and made some serious progress at getting rid of useless paper. And I started to evaluate what I had in terms of "what would make for good writing material?"

That time around I managed to condense what I kept into a 2 gallon ziploc bag.

So on Tuesday [2011 -- sensing an every-other-year pattern here?] I went through my writing material stash and started to get serious about categorizing what I had. What I ended up with, after 5 hours, was essentially three piles and a whole bunch of ideas.

So I'm going to try to seriously work on writing some of these stories, instead of letting them collect dust in sealed ziploc bags...

Stay tuned....

Sometimes, it's actually pretty handy....

That I have a medical degree.

• For instance, Saturday morning when I woke up feeling like crud, it was pretty easy to run a rapid strep screen at home on myself. Granted, that's not in the usual home first aid kit, but I've accumulated "stuff" over the years.
• Then when the test came up positive, it was pretty simple to just write my own prescription for good old fashioned amoxicillin. Not that I self-treat that much. But seriously -- on a Saturday, if I bugged my internist with this, even she would wonder why I just didn't write my own 'script. And she is way more conservative than I am in regards to antibiotics, etc.
• Although, I didn't really study veterinary medicine, I've picked up enough along the way; so that last weekend when Zoe the dog sliced her hind paw, I had a fairly good idea of what to do for canine first aid.
• Same deal when Brie the cat hurt her left eye. [And that one was ugly, even by my standards....]


But tonight really takes the cake.

Tabitha, being the "No Fear - Full Speed Ahead" kind of girl she is, has damaged herself in multiple varieties in the nearly 5 years we've had her. A few episodes that come to mind include:

• There was the time that Miss H & Miss E had to fireman-carry Tab home, as blood dripped from the abraded surface of her knee, down her leg, and soaked her sock & shoes.
• There was that time she slipped on a puddle in the girl's restroom at school, somehow slid into a stall and stopped when her arm slammed into the toilet base. [I actually got x-rays that time, because she was crying so hard I really couldn't tell if she'd broken anything or not.]
• There was the time in our master bath, when she went to show Michael how she could do a back layover. She over-extended, then fainted, and walloped her face into the tub surround on her way down to the floor. She spent the next week with a really ugly shiner and a concussion. And Michael spent at least 48 hours shell-shocked....
• Then one of my personal favorites was the time that Michael & I came around the corner and found her splayed out on the sidewalk. She'd decided to wear flip-flops to ride her bike. Hit a rock on the sidewalk. Lost her footing and slid. Then subsequently her toes ended up caught in the spokes of her front tire. [I did manage to render aid without saying "I told you so", but she's never questioned me since when I tell her to wear "real shoes"....] Total damage was lots of scrapes & bruises, a torn up toe, but no broken bones.
• Just a month or two ago, she was cleaning out her school notebook and held up her hand. As I looked up from washing dishes, I noticed that she was dripping blood on her papers. She noticed at about the same time and that's when she came un-glued. Turned out to be an extremely fierce paper-cut.

<Sigh>....Over time she's had lots of bruises, scrapes, etc. So far [knock on wood], no broken bones. But she really does not like the sight of blood. And she especially does not like the sight of her own blood.

Hence we come to tonight's episode....

At about 9:45pm, this very sad, wet, bedraggled Tabitha shuffles into my office, holding a white towel to her head and weeping. She holds the towel out to me and there's large areas of blood staining it. At that point she sniffles and managed to tell me that she fell getting out of the bathtub in her bathroom.

[An important detail, as she does not pick her things up off the floor, nor does she keep the floor dry while she bathes, so it's always a slip hazard. And don't worry -- I have mentioned this to her many times before....<sigh>....]

As I looked her over, I noted the large amount of bright red blood on her crown. I started dabbing it away with the towel, but couldn't really see where the bleeding was coming from. It took a few minutes to really get her cleaned up. At which point I discovered this was very superficial from a 1/16th inch scrape on her scalp. [Scalp wounds! Ughhh! They always look so bad.]

By this point she finally had told me what happened, and yet once again we were lucky to avoid the ER.

She was getting out of the tub while it was still full & very wet, stepped on a wet tile and slipped. At which point she fell backwards & bonked the top of her head on the point of the ceramic soap dish that's molded into the shower/bath surround.

Since she was complaining of a headache, and dizziness, and nausea- well she's likely got a concussion (Again!). So she got some tylenol and an icepack, and in a few minutes I'm going to go peek at her pupils....

At anyrate, I'm very glad she didn't go to Michael first, or I would have had two patients -- and I don't keep suturing supplies around the house....

Just another day of misadventures in my TAME world....

 

 

Not much going on....

In my neck of the woods.

Routine day in clinic. Patient of the day was one of my many teenagers today. [Seems like I saw more of the 13-17yo set today than usual.]

Anyway, Jake* was there for a check-up, but really was there because his acne was bugging him. Or more accurately was bugging grandma. Poor guy! I really felt bad when Grandma fessed up that she'd been using rubbing alcohol on his face to clear up his skin. Ouch! I kept repeating in the visit that I just want him to wash his face gently with a mild cleanser. I sure hope she got the point.

So got home this evening to an empty house. Michael & Tab got a wild hair and had signed her up for a Tae Kwan Do 101 class. At a loss for what to do, I got dinner started & hit the treadmill.

It was pretty funny when she got home at 845pm & proceeded to demonstrate what she'd learned tonight. There was this whirling deverish of a white gee spinning around the living room. Lord help us - in apparently 2 belt levels she'll qualify to spar. Mark my words - this will not end well....

And speaking of whirling deverishes, poor little Zoe is finally starting to bounce back, quite literally. Sunday morning she cut her hind paw up in between the toes. Blood all matted up in there. Pure misery. Michael "thought" there might be a problem because she won't walk on it. Dr-Vet-Mom to the rescue. [Really?! I went to medical school for this!?]

Basic first aid later and we nicknamed her "Tripod" for the weekend because she wouldn't walk on the foot. She's just a touch of a drama queen. [Really - I have no idea where she gets this from!] So this evening it was feeling lots better because she hopped twice as I walked in. Just call me Dr Doolittle!

Otherwise, I'm drowning in digital photos. I spent the weekend being photographer to the family and now I need to download, sort and purge. Might I add, I haven't even looked at my own pics of Christmas yet....

That being said, I'm cold and achey, and given my flu exposure these days, I'm going to call it a night early, & go snuggle Merlot and my electric blanket.

Anyone need a good laugh?...

So in clinic this week, I had a first.

I was seeing this adorable, round 15 month old boy, who was delighting in showing off how well he was walking now.

As I was talking to Mom and granddad, I could tell that Junior was toddling up behind me. I thought he was headed for the rolling doctor stool that was behind me, so I hooked my foot on the base to keep him from rolling it away. Next I know, it's gotten very quiet and I was sure that he'd decided to try to climb up on the stool....

As I turned to check, he reached up his chubby left hand & pinched me on the tush!

Oh -- poor Mom was horrified and Grandpa was roaring with laughter in the corner. Three guesses who Junior probably learned that from!

Like I told Michael, that was the first time I'd had a 15 month old male truly make a pass at me!

Good times. And I'll remember this little guy for a really long time!!

 

Survey says....

That it's "been a day"....

A day filled with 335 questions over 7 hours. Tough questions too. I'm almost afraid to admit that I feel cautiously optimistic; especially since a) rarely do I ever feel optimistic and b) I don't want to jinx myself. Still I approached the board exam today with a genuinely different attitude and I think it helped. I know that today I did as much as I possibly could.

For those just joining my saga, today was my fifth attempt at taking the Pediatric Boards. I've talked to the ABP folks myself, and I'm not making up the fact that this exam  they have designed to fail 60% of the test-takers annually. Seriously. I'm not making that up. I learned that after I failed the third time, because at that point they will talk with you directly to analyze your scores & help you figure out what you keep screwing up. Sporting, right!?

So long story short:

1. First year, I was a lamb to slaughter. I took the exam because everyone else from my residency did, but I really had no idea what to expect or what to study. My particular program at the time was way more focused on turning out bright clinicians & not bright test-takers.
2. Second year, I put so much pressure on myself to pass, that I completely undermined myself. My test anxiety was so bad that between sections I had to visit the restroom to vomit -- never a good sign....
3. Third year, we had just found out that we were leaving for our first trip to Russia 3 days later for our adoption of Tabitha. At that point I would have been wiser to just forfeit the fee, because my brain was on a trans-Atlantic flight already. It was definitely not in the testing room.
4. Fourth year, I decided to try again, even though we'd only had Tabitha home for about 6 months. The transition was fairly stressful, and I was still primarily thinking/interacting with her in Russian. It just didn't translate well that year.
5. By the next year, I was fed up and decided to take the year off. I had no interest in studying. My locums practice was growing, and I wanted to actually enjoy the Summer with my daughter. Then last year, I decided to try again, only to find out that I'd missed the registration deadline by 6 hours. Which turned out fortuitous since my pulmonary emboli at the end of August would have derailed my ability to study & think.
6. This year, I decided to try again. As Micheal put it, this d*** test has become a point of pride and intellectually, I won't be happy until I get the title "board certified". So I sucked it up, studied pretty hard, and tried as many different strategies as I could to make it work this time.

So now it's sit back, hurry up, and wait. Results will be released "by January 15th, 2010". You would think that for $1750 and two scan-tron sheets I could find out sooner, but apparently No.

So knowing how incapacitating test anxiety has been for me in the past, I fell back to an old coping technique that I used to survive medical school. I basically sleep deprived myself. That way I had enough energy to take the test or to be nervous, but not both. I checked into the test site hotel at 5:30pm Sunday. Ordered room service, instead of going out to dinner with friends. Settled in and crammed/reviewed about 500+ pages of material over 6-7 hours. Went to sleep about 3am and was up at 6am Monday morning. And before bed, I tapped into my Catholic girl roots, said a couple rounds on my rosary beads & got on my knees to pray for 20 minutes. I figured that at this point it couldn't hurt to really ask for some divine intervention....

I managed to pack up & check into the testing room on time. I know! Definitely a completely novel experience for me... Had breakfast via room service again instead of being around the other test-ees; so I would avoid picking up their nervous energy. I actually did my damnedest to avoid being around anyone today and that helped a lot.

Instead of going in my usual causal jeans & sweats a la schlump-a-dinka, I dressed up a bit. I was styling in a silk blouse, dress jeans, my favorite bling necklace and my absolute favorite pair of taupe patent leather kitten heels. Now if/when I pass, I probably shouldn't give all the credit to this one pair of shoes, but wearing them & hearing the "click clack" of the heels always makes me feel confident & in control and I carried that into the testing room with me.

Instead of being in the front of the room, I was in the back of the room. Instead of mechanical pencils, I used plain jane old yellow #2's, pre-sharpened at home of course. I brought my trusty ear plugs & used them to zone out & focus on my test book. That cut down on the distractions drastically. Due to fatigue, I abused the caffeine a bit much today, but since I arriving home at 6pm, I've been sticking with water & should be all evened out tomorrow.

Over all, compared to prior years, it felt like I could see through the bulls*** more clearly in the questions. I found myself thinking of the answer & then looking for it in the choices instead of searching the choices for something that might work. The format was different also. In years past there were lots more questions over two days, with the second morning devoted solely to the "picture book" or photos/x-rays, etc. Now those were just sprinkled in. There weren't any of the long matching questions, i.e. 5 questions with a potential 10 choices. And there weren't any of the "multiple, multiple choice". You know the ones that list out option "a,b,c,&d"; but the actual answers are "a&b", "b&c", "a&d", "all of the above", "none of the above". Yup. Didn't see any of those.

And every year, it seemed that the exam had a theme. One year it was heavy with Neonatology questions. Another year it was all Cardiology & Endocrinology. Another year it seemed like it was all Cancer. This year? Not so much. It seemed like it was heavy on Adolescent medicine & substance abuse. There was a fair amount of reading x-rays (something I like & am good at), a fair amount of reading EKGs (again, something I like & am good at). Lots of immunization & preventative medicine questions; lots of Endocrinology & Rheumatology; some Genetics but not so much Cancer or GI. And two of my stronger areas, Newborns and Dermatology were all over the exam.

And if you're one of those "God works in mysterious ways" kind of people, you'll love this. He does have a sense of humor. When I got down & prayed, I specifically asked for certain topics to be on the exam: Adolescent, Newborn, Derm, General Peds, Genetics & Rheumatology. I did not ask for certain things to be left off -- but he knows how Oncology has been a serious struggle for me in the past. Too heart breaking dredging up past memories. And then if I needed some signs, well my hotel room # was 303 and 3 has always been my lucky number. My assigned test seat was #111, which equals 3. I'm just saying.... Could be coincidence, but I think not.

So I got done. Came home. Was apparently missed by all the 2-leg & 4-leg critters. Got to have a fabulous steak dinner, and about now I'm ready to head to bed. I've got a bit of down-time this week and I think I've earned it.

I'd like to say a big

THANK YOU!!

for all of the encouragement I received over the past few days. Just as I was finishing up this evening, my phone was slammed with FaceBook texts from all over. Knowing that I had a big cheering section helped me stay calm today at a few key points when I wanted to panic. So please know, you were very much appreciated. Over the next few months, if you have some random thoughts for a passing score, I'd really appreciate that too!

So when I know something - I promise I'll share....

Looks like I'm "board" again....

24 hours from now, I'll be sitting for the Pediatric Board exam for the fifth time. I very much would like to think that "fifth time's the charm!" and that this will be the last time I have to do this. At least until recertification in 7 years....

If you need more background, go read this post.

At any rate, I'm shutting off the computer and turning off the ringer to my cell phone for the duration. Texts & FaceBook messages still come though to my phone, I just can't reply. I expect to be back late Tuesday night. The exam is now only one day, instead of two. [ But $300 more expensive. Exactly how does that work???? ]

If you happen to be a praying/kharma/good energies kind of person, I would appreciate whatever good thoughts you'd send my way.

Catch 'ya on the flip side....

Fall has arrived and I'm contemplating the current condition of medicine....

In the past 2 days the temperatures have dropped into the 50's.

In our household, it's the start of Fall when Michael officially declares it's time for "Marshmallow Deployment" AKA getting the down comforter on our bed and into the duvet cover. Last night I thought aliens had replaced him because he started talking about adding flannel sheets. This is my husband the polar bear, right? Now that I know the joys of my low voltage electrical blanket -- I'm roasty-toasty no matter what. And after this week, I needed the sleep.

Fall weather in North Texas brings the start of Mountain Cedar Season, aka "Cedar Fever". Allergies go "boom" and asthma kids start wheezing out of the wood-work. Add to that, my region is now in the fifth week of widespread flu activity, primarily with the H1N1 strain.

I filled in at a clinic out in semi-rural Texas west of here all week. Drove 2 hours a day hither & yon. The practice recently moved to a new building & I like the new place a lot. So much easier to see people without tripping over the staff. Of course, I know I'm in the boondocks when the baby girls come in dressed in camouflage. In a week where I saw about 80% flu, the most memorable patients this week were:

• the 3 year old with the broken collar bone. Happened the week before when he tripped exiting a large plastic play car and then it fell over on him. Definitely a fluke event. Got seen in the ER the night this happened & since the parents were focused on the kid not moving his arm, apparently that's all the ER x-rayed. When I saw him, I poked all over his spine, shoulder, chest & back. And sure enough, part way down his collar bone he started howling and I could feel the ends of the bone crunching. Always a delightfully squeamish physical finding. Got the chest x-ray done & mystery solved. I felt pretty good about that one, just because I picked up the fracture without the x-ray.
• 13 year old with 2 week history of intermittent, escalating abdominal pain. Seen in the ER x2 already with a "normal work-up". On exam this patient was very obviously overweight and had classic signs of gallbladder colic, especially a positive Murphy's Sign. I got all the blood work & belly ultrasound ordered, but the week ended before I found out results....
• 13 year old with 6+ months of intermittent, escalating abdominal pain. Already worked up and treated for reflux/chronic heartburn. Skinny kind of patient and very firmly denying that the reflux meds helped at all. After multiple doctors & multiple visits, I guess I was the first person to ask "What makes the pain worse & what makes the pain better?" Seriously. I was floored at the answers and this is yet another example of "if you listen to the patient, 80% of the time they'll tell you what is wrong." Turns out the pain hurts more upon getting home from school (where there's a lot of fighting: between sibs, between parents, between kids & parents, etc....). The pain is better with distraction like TV & movies, hanging out with friends, not being at home, etc. A little more probing reveled that this was a "Yours, Mine, Ours, blended family" and that the chronic stress and anxiety were wearing on this kiddo. No wonder the reflux meds didn't work -- that wasn't the problem. One referral to counseling and some in-office encouragement and on to the next patient....
• 7 year old with classic flu symptoms and a loud heart murmur that sounded like an unbalanced washing machine. I noticed a very faint surgical scar at the top of the breast bone and over the big neck veins, paused as I thought "hmmmm" to myself, and then looked at Mom to ask "Exactly what kind of heart surgery did this kiddo have?" At which point Mom was gracious enough to look bashful with "Oh Yeah! I meant to mention that at 11 days old, they did a truncus arteriosus repair and there is still a leaky valve...." Good to know these ears of mine won't miss the obvious....
• 7 year old with classic flu symptoms, who had been seen by me on Monday and diagnosed clinically with the flu. Tuesday, the patient still had a fever, so Mom took'em to one of those new "Minute Clinics" that are showing up around town. They brilliantly diagnosed a fever and a cough and prescribed a codeine based cough syrup. [In my book, generally not a great idea since kids have this odd little idiosyncratic reaction to codeine and it can cause them to stop breathing. I always tell parents the reason I won't give them one of these cough medicines is because "I lose style points if I kill off my patients with cough medicine." Of course, I guess that is one way to stop the coughing....] Mom decided that on Wednesday, since the fever was still there, the patient needed to be seen again. Since she didn't feel real confident about the Minute Clinic, she came back to the Pedi office. Still looked like the flu, although now the patient actually had an appetite. Turns out Mom hadn't even filled the cough syrup prescription and that really, all she wanted was a test to prove that this was the flu. One snot covered q-tip later -- and Yes it was Influenza Type A positive. Then Mom wanted me to do something to "cure the patient" so they could do some school outing on Thursday. Needless to say, this is an example of the unrealistic expectations that run rampant today. And just so you know; back on Monday I had told Mom to expect about 5-6 days of "off & on fever" and cough, and to stay home from school until next week. And the office had given a school note to that effect.... Some days I LoVe parents!
• 7 year old with classic flu symptoms, who had been doing well and then 7 days out came down with a productive cough & 104 fever. On exam, the chest was dull to percussion at the bases, there was less movement of air, and there was egophony. 1+2=3. This was a clear case of pneumonia setting in. I didn't need the chest x-ray to start antibiotics, but the parents wanted it done. And sure enough, early infiltrates bilaterally in the bases. I'm sure that my professors from 1st year med school would be thrilled that I still know what egophony is, but this 7 year old & parents thought I has lost my mind when I instructed her to keep saying "e" over & over....

And this was how they did medicine "back in the day" before everyone got scanned & radiated for every complaint....<sigh> Sad isn't it, that I expend the brain power and use the physical diagnosis skills and generally don't run up a huge lab/radiology tab -- but still, as a Pediatrician, I am at the bottom of the food chain for health care reimbursement because I don't "do" things to patients. Same thing for most of my Family Practice & Internal Medicine colleagues, 'cept they have much bigger, more complicated patients to deal with....

Numbers-wise, I saw between 20-30 patients a day in an 8 hour day all 5 days this past week. I also managed another 25-50 patients per day by telephone daily at this same practice. Roughly that was about 50 to 80 patient encounters each day. I ate my sandwich, from the lunch I packed each night, in about 10 minutes each afternoon while I tried to write in charts & catch up on billing sheets. Most days, I had a chance to go pee once in that 8 hours. The phone calls, by-the-way, were all at no charge. Since really, who these days actually pays for medical advice they receive over the phone. Patients expect that doctors will provide that as a free service.... And at this practice, the nurses told me this was slow for them. This doc routinely sees 40-60 kids per day in an 8 hour day, with about the same number of phone calls. In order to pay the bills, the typical pediatric practice needs to see a minimum 25 patients a day. The more staff  and the higher that number goes. Most of the practices I fill in at routinely see 50+ patients per day. Honestly, I'm pretty appalled that's the standard of care in my region. But insurance reimbursement and economics are the main forces that have created this situation.

I never went into medicine "to get rich". But I certainly never went into medicine expecting that the patients & parents would value my services & time at  the $15-$25 copay. They would gripe & complain about waiting more than 20 minutes to be seen, and that some days it would feel like the plumbers & auto mechanics of the world get more respect than I do....

Is it any wonder why there is a shortage of primary care doctors? Any one surprised that the shortage is expected to get drastically worse over the next decade? And frankly, based on what my average day sounds like -- would you want to do my job?

In contrast to the above, evenings this week I've been fairly steady with my house calls practice. I do see families with multiple kids. When I visit the first time I try to get my baseline data for all the kids. That way when I get a phone call that so & so's brother/sister is sick I already have a physician/patient relationship and can provide telephone advice. In my own practice, right now I don't charge for phone calls. I may have to change that. If I come and see the child, I charge $150 up front. Cash or Check, no credit cards. If over the phone, the problem sounds like I really need to examine the child, I say so. If the problem sounds like it is outside the scope of care I can provide, I say so. If I think an ER eval is needed, I call ahead & talk to the ER triage on duty to facilitate care, but typically I'm seeing the child at the time and conveying my findings directly to the doc on the receiving end.

So far, I have yet for any parent to tell me that my fee was was too high. A few have even said I should charge more.... [Hmmmm????] What I'm finding in that with the standard doctor visit lasting 7-10 minutes or less, most of my parents are absolutely starved for time to spend with a doctor, have all their questions answered, and receive insightful feedback on issues related to their child. And to them, $150 is money well spent. One family I've seen recently, most of my visit was spent explaining blood work results for their child, that had been ordered by a different doctor. I routinely go through medicine cabinets and help parents decide what to keep, what to toss, and what doses to use for their children. I'm a firm believer in "cheat sheets" i.e. legible notes left for Mom & Dad with written instructions on what to do and what to watch for in their kids. 

So am I a-typical in the Pediatric world? -- Yup! So do I wish I could provide this standard of care to every child I see, even on my locum tenems assignments? -- Yes, but only if I were compensated appropriately for my time. Do I mind being so directly accessible to my patients, i.e. Mom & Dad have my personal cell phone number. -- Not so much. The latest anyone has ever called me was 2145pm and the earliest was 0830am. Once they realize that they really do get me and not some phone triage message with three layers of nursing/receptionist staff to go thru, most parents really won't call unless they are extremely worried.

Eventually, I hope that in my local area, my practice will build big enough that I can just do this full time. The intangible reward I get for sitting down & spending that hour with the kids & parents is the gratification that comes from really knowing them well and being significantly helpful to them. For example, in one family with two children, I've visited twice. Talked to Mom on the phone 4 or 5 times, and I can tell you that I know both their medical/family/social histories considerably better than their regular pediatrician. Sum total of time spent? About 3 hours. Income made? $300. Work stress? Zero. Do I enjoy what I do? Absolutely love it! No insurance hassles. Very minimal paperwork. But most of all, to me, this feels like the way medicine should be.

The Flu & You -- Part Deux....

Here's another Flu PSA that I love.

Turns out that the Dept of Health & Human Services had a "Make your own Flu PSA Contest" earlier this year. Dr. Clarke was the winner & seriously I love his style. I'd save myself so much time if I just had that playing on the background at every clinic that I locums at....

If you want to see the finalists, you can find them here.

The Flu & You....

For my public service announcement today, I bring you the Amazing Dr. Clarke: [Remember, "Laughter is the best medicine!"]