Saturday, January 25, 2014

Re-entry

Wow - happy almost-one-year anniversary of my last post on this nearly defunct blog!

It's hard to write about patients when I'm afraid that (even with many details changed) an owner could recognize their dog or cat from my post, and it's hard to write about work when I spend so much time there and would rather think about my family when I'm at home!

To briefly recap, since my last post I:
  • Saw hundreds more patients (duh)
  • Celebrated H's 2nd birthday (!!!)
  • Had another baby (a girl! Little E was born in October)
  • Am enjoying the heck out of an extended maternity leave (I've been off since 2 weeks before I delivered, and go back at the end of February)
  • Have realized that there is no way in hell I could ever be a SAHM (I ADORE both children, but I need to get out of the house and do work that is intellectually challenging, and I sadly lack the patience for remaining cheerful in the face of the one thousandth, "Mommy, I need [x]!" of the day)
I did strongly consider not going back to my current job. It has a lot of advantages:
  • Extremely well-equipped hospital
  • Specialists on staff
  • Decent client demographic
  • Decent salary
  • I really like my supervisor 

But also a lot of disadvantages:
  • Specialists on staff :)
  • Longish commute
  • Crazy long hours - I'm gone for an average of 15 hours on my full days, which while short by the standards of vet school or internship/residency, is a lot longer than I want to be working as a general practice associate
  • Way more interpersonal drama than I ever could have imagined
  • Some of the management staff are borderline crazy

(BTW, specialists appears on both lists because it is REALLY nice to have a specialist immediately on hand to ask questions of every now and then, and it's great to be able to transfer very complex cases to them. On the other hand, they have a tendency to be condescending and critical of GPs' case management [whereas external specialists are generally nice to you since they want you to keep referring to them; internal specialists don't have to worry about that since you pretty much HAVE to keep referring to them, so instead of, "Hi, Dr. LIVS! Thanks for the referral! Here's what I think of the case...", I get, "Hey, Dr (and I use that term loosely) Dipwad, your workup of this case SUCKED (did you even GO to veterinary school?) and you really should not even have touched the patient before referring them to me. Try to pretend that you have at least 3 functioning brain cells next time."] which is kind of demoralizing, especially when I stayed 3 hours after the end of my shift working on that patient the day before.)

Anyway, I considered either not going back at all (maybe doing a couple of weekend vaccine clinics a month to supplement our income), or looking for a job at a more local hospital that is more of a traditional GP clinic (rather than a 24 hour hospital). But the weekend vaccine clinic thing would kind of be the worst of both worlds - I'd be a SAHM who ALSO worked weekends, and MM and I would only get 1 weekend a month together, since he also works one weekend a month - and wasn't quite enough income (and isn't intellectually challenging at all). And when I met with my supervisor to discuss returning to work, it turned out she was willing to give me a SWEET schedule, and management agreed to convert my previous salary to an hourly wage (based on SCHEDULED hours, not hours actually worked, so I effectively got a 15% hourly raise since I always got stuck at work way beyond the end of my shift), so I'm going back.

I'll be working 2 days a week (technically 6 hour shifts, but I know they'll turn into 8 hour shifts most of the time - which I'm a lot more okay with since I'll be paid for the whole 8 hours!) and 2 Saturdays a month. I could pretty much not have asked for a better schedule than that! And we'll be a lot better off with 2 incomes, even if mine is just part-time -- student loans, rent, health insurance, and part-time daycare cost us about $4000 a month (just for those 4 expenses!!!). We would have had to cut out pretty much everything not absolutely essential, and completely freeze saving for retirement, if I didn't go back to work. Finally, again, while I adore the kids and love spending time with them, when that's the only thing I do, it becomes work - it's my job. When I'm working outside the home, the time I spend with the kids becomes my fun recreation, which is much better for my relationship with them.

Sunday, February 10, 2013

More cancer

I missed a giant tumor last month. A dog (old, large-breed) came in for coughing, and the owners thought he had kennel cough, because he'd been groomed a week before. I was more worried about other things, given his age, and took chest rads. There might have been some hilar lymphadenopathy, but it wasn't dramatic. The cranial abdomen was also in the films, and I took a quick glance at it and noticed a little piece of bone in the stomach, but he has a history of dietary indiscretion so I didn't think too much of it, and went back to ruminating over whether the hilar lymph nodes were actually big or not. Well, he came back last week, for GI upset, and had a large splenic mass removed. So I went back and looked at the rads I took a month ago, and there is obviously a splenic mass on those films. It was squishing the stomach. I totally missed it.

I also (tentatively) diagnosed a dog with ALL this week. That was pretty bizarre! I can add this one to my list of patients who came in with diarrhea, and went home with terminal cancer. The peripheral blood was so screwy that our machine couldn't even read the CBC, so I made a smear, and there were abnormal lymphocytes EVERYWHERE. They almost outnumbered the RBCs in circulation! No peripheral lymphadenopathy. Giant spleen. Referred him to an oncologist, but it probably won't matter much. The owners were very upset, cried a lot, and asked very thoughtful questions - I was impressed. I'm very curious to see if the oncologist agrees that it's ALL.

Another dog came in with hematuria, and ended up having a giant bladder mass. That client can't afford surgery or chemotherapy, so she'll probably be euthanized soon. She was mildly coagulopathic and moderately thrombocytopenic, so I'm actually more worried about bleeding out than about the mass, in the short term. I didn't recommend a transfusion, because at my hospital it costs almost $1000 and the guy could barely afford the $500 in initial diagnostics, but in retrospect I wish I'd at least mentioned it.

On the pettier side, I got yelled at by a client this week on the phone. Her husband had brought in their geriatric cat on emergency, with urinary signs. I recommended a urinalysis, abdominal radiographs to look for uroliths (and tiny or giant kidneys), and bloodwork, both to look at her renal values and because she was also not eating very well. I didn't push him to do all those things, I just explained why I was recommending each thing, and he opted to follow that plan. She did end up having an uncomplicated UTI, and the wife was furious that I hadn't JUST done a urinalysis. She even talked to her regular vet, who AGREED with her that my plan was excessive and unnecessary. I explained that even if I'd just done a UA, the cat STILL could have had bladder stones, neoplasia, GI or liver disease, etc, and finding a UTI doesn't rule out any of those other possibilities. AND that I hadn't pushed her husband into following my recommendations, I just made and explained my plan, and he elected to follow it. She was still disgruntled when we got off the phone. The part that really galls me is her other vet telling her the rads and bloodwork were unnecessary and excessive. I would never say that about another doctor. Especially since I still think it was a perfectly reasonable plan.

Being a doctor is really stressful. REALLY stressful. I'm constantly worried about missing something, not ordering the right diagnostic tests, not interpreting the tests I DO order correctly, not asking the owner the right questions to elicit the complete history, making a mistake with a drug dose or combination . . . . . . . I frequently wake up at 4 AM and can't go back to sleep because I'm so worried about patients I should have pushed harder for, or should have done another diagnostic on, or should have explained something a different way to their owner, or should have emphasized something harder. It's stressful.

Wednesday, January 30, 2013

Fluff

I have to mention my new favorite material possession, because I use it every single day. It's the Take Me With You bag from Lululemon. I saw it in the store (it's the only thing I've ever bought from them!) and loved it, and I've been looking for a BIG tote bag with LOTS of pockets forever. I mean, I have spent many hours combing the internet for the perfect bag, and haven't found it. Until now. So the price tag initially prevented me from buying it (it's $148!!!!) but after considering how much I would use it, how durable and well-made it is, and how much more free time I would have if I could stop looking for a stupid bag, I went back and bought it. This was about a month ago, a few days after Christmas. And I LOVE it. It makes me happy every time I see it. :) I bought the black and white one, and the lining is electric blue, and I really love this bag.

I also bought a little tin of Trader Joe's dark chocolate-covered chewy caramel squares last week, and at THE WHOLE TIN in the past week. MM ate a couple, but I ate 90% of them. At least. So of course when H and I went grocery shopping this morning, I bought another tin. WTF?!? I do not run enough these days to put away a whole box of chocolate covered caramels every week.

H is being weaned from his papi (what he calls his pacifier) because at his 18 month checkup, the pediatrician gave me the side eye when she saw him sucking on it, and I don't feel like wading through years of PubMed looking for peer-reviewed articles on the effect of prolonged pacifier use on orthodontic development, so I'm playing it safe. She recommended reserving it for sleep, which I thought would be nigh impossible - he LOVES this thing, and when he couldn't find one, he used to walk around the apartment, crying softly and plaintively calling, "Papi! Paaaapiiii!" like one of them was going to hear him and come running. But it turned out to be great!!! The morning after that visit, when he woke up we asked him to leave papi in his crib, because papis are for sleeping and he's awake now, so he doesn't need it! But papi will still be there waiting for him at nap time. He looked at us for a minute or two, considering, and then dropped it in the crib and never looked back. Now it's an awesome incentive to take a nap, because we can hold out the promise of papi, which he is always thrilled to see. AND, his speech has totally taken off now that his mouth isn't full all the time. He talks SO MUCH!!! He's starting to say 2-word sentences, and his vocabulary of spoken words includes at least 50-100 words. His vocabulary of understood words (things he can point to if we ask, but doesn't pronounce yet) is at least another 100 words. I love listening to him talk!

It snowed the other night, and it was a BEAUTIFUL fluffy snow with perfect individual snowflakes. It's really weird - my entire childhood, I looked for snowflakes every time it snowed, and never saw any. I feel like it was always, invariably, the kind of snow that's just tiny little particles. NOW, I see them in at least two snowfalls a year. I don't know if the snow has changed, or if I just never saw them for some reason when I was a kid, but I LOVE snowflakes! H loves snow, and points it out every time we go outside. We took him sledding the last time it snowed (on a cookie sheet, cause we're ghetto like that . . . . . . . apparently that's how I afford $150 bags, by depriving my only child of a proper sled) and he seemed to like the IDEA of sledding, and loved it when MM or I would go down the hill, but when we put him on the sled (er, cookie sheet) he would get this very tense look on his face and then just lay there stunned at the bottom of the hill until we retrieved him (it was a tiny hill - it's actually just the slope up to one of the other apartment buildings in our complex, and it's a slow 3-second ride to the bottom), so I'm not sure how much he actually likes sledding. Maybe if he had a real sled . . . . . . .

I am feeling completely betrayed by the book I'm reading. I usually listen to NPR in the car, and they were interviewing Ayana Mathis the other day, whose debut novel is called The Twelve Tribes of Hattie. It's about a woman who moves from Georgia to Philadelphia during the Great Migration in the 1920s, and Mathis read the first 4 paragraphs during the interview -- it was so beautiful, so happy, this young woman in her first house in the beautiful early summer, with her sweet newborn twin babies, and the whole neighborhood suffused with the scent of strawberry cakes that everyone left out to cool on their windowsills. She's a wonderful storyteller, and I could picture the whole scene, and it was so lovely, and happy, I ordered the book as soon as I got home that night. WELL, **SPOILER ALERT** those sweet little twin babies, who in that excerpt were napping on the porch with their mother, listening to the chirping birds in the trees overhead, DIE OF PNEUMONIA before the end of the first chapter. I stayed up way past my bedtime last night, trying to reach a point in the book where I felt like it wasn't going to all be tragedy, and I got too tired to keep reading before I ever got there. Mathis is a brilliant writer - I was completely invested in the characters before I'd finished the first PAGE!!! But the book is tragic, and I hate that. I feel like the excerpt they featured on NPR was completely misleading, and I'm upset about that!

We've discovered a new TV show (new to us, I mean). It's a BBC production called Sherlock, and it's a modern retelling of the Sherlock Holmes story. It's freaking brilliant, and the guy who plays Holmes is absolutely perfect. Each season only has 3 90-minute episodes, which is unfortunate. But the first 2 seasons are on Netflix, and we're really enjoying them.

Sunday, January 27, 2013

The big C

I've been on a cancer spree lately. It got to the point where I was irrationally almost afraid to see patients with diarrhea, because that's how they kept presenting. I had two patients in a row, both older dogs, who presented with diarrhea and ADR of several days' duration. Fine otherwise. One of them, a boxer named Baxter, ended up having a bleeding splenic mass, and I referred him to the nearest university hospital because I'm not a radiologist and couldn't be 100% sure of the source of the bleeding, and I knew he'd need surgery (and probably chemo) if they wanted to treat him and I've never done a splenectomy. Those people were nearly hysterical, and I spent almost 2 hours with them, on a day when we were slammed with other emergencies. Luckily we've started a new pilot program of scheduling 2 doctors for part of the weekend when we tend to get a high ER caseload, so the other guy was free to see the cases that came in while I was counseling this family. It was very sad. :( He ended up going to the university hospital the next day, had a giant bleeding splenic mass, and they euthanized him.

My next diarrhea patient was another older dog, a Great Pyrenees named Snowy, who seemed fine other than diarrhea and decreased appetite. Liver values were very (VERY) elevated, and abdominal rads were very suspicious for a cranial abdominal mass. His ALT was over 7000 U/L, which I have never seen before, among other abnormalities. I couldn't definitively diagnose him based on the rads and bloodwork, so we hospitalized for supportive care, and I took a brief look with the ultrasound probe to see what the liver looked like before I called my senior clinician for advice. There was a HUGE hepatic mass. I talked to that family at length too, and they didn't want to put him through surgery or chemo since he was a big dog who was already 12 years old, and just wanted to keep him comfortable for as long as they could. He went home after 24 hours in the hospital, and came back a day later for euthanasia. That was a really sad case -- his family was SO nice, and loved him SO much.

After that, for a couple of days, every time I saw "diarrhea" as the presenting complaint on my appointment schedule, I was like, "NO! They don't want to see me! I'll give them cancer!!! They need to see a different doctor!" Which of course was ridiculous and irrational, and I have not diagnosed another dog with cancer in over a week. Whew.

You know what I still have yet to see? A mast cell tumor! How can that be?!? They're the most common cutaneous mass in dogs! And I've never even seen one! MM texts me iPhone pictures of his MCT cytology on literally a weekly basis. Part of it is that we practice in very different socioeconomic areas, and my clients only agree to cytology of suspicious masses about 30% of the time. I think part of it is that I don't push them as hard as he does, which I should do. I always feel obligated to present the pros AND cons of any procedure when I recommend it, and I warn people up front that sometimes masses don't exfoliate well, and we may not be able to get a diagnosis from FNA, at which point I would recommend biopsy. Then of course they say no to the FNA. He just says, "I'm concerned about this mass, and we should aspirate it and do cytology to get a better idea of what it might be". I ALSO always volunteer them the option of just keeping an eye on it for now, which is a stupid thing to do. What I SHOULD do is recommend cytology, and if they ASK if they really have to do it, then I could say no, you could keep an eye on it for now and bring her back if it changes at all. So, it's possible that what I really mean is that I have not DIAGNOSED any mast cell tumors. I may have SEEN several and just not gotten to do cytology.




Saturday, December 29, 2012

At least she had a seizure


You know your patient's neglected if . . . . . . .



. . . . . . . upon discussing all the (long-ignored) problems she has, your nurse comments, "Well, at least she had a seizure, so she could be seen".



Poor dog!

Saturday, December 8, 2012

Fun client phone calls

I got a phone call from a guy yesterday, asking about his dog, Effbee. The dog has had diarrhea for several days, so he's been treating her with Immodium. The man is not a client at our hospital, and I've never seen his dog. When I got on the phone, the receptionist had already recommended that he bring Effbee in to be examined, but the appointment schedule was full so they'd have to come as an emergency walk-in. He declined that option, and wanted to know if it was safe to keep giving her Immodium.


[LIVS]: Hi, this is Dr. LIVS, you're calling about giving Immodium to your dog? Tell me more about what's been going on with her, and how much Immodium you're giving.

[Guy]: Well, she's had diarrhea for days. So we've been giving her Immodium . . . . . . . . . and it's gotten worse and worse. Then yesterday she started vomiting, and she hasn't been able to eat anything. I Googled a bunch of things, and I just wanted to know if it was safe to keep giving it to her. I've given her four tablets in . . . . . about two days.

[LIVS] First of all, I'm concerned about the fact that the diarrhea has gotten worse, and that she's vomiting and not eating. This could be caused by many things, some of them very serious, and I strongly recommend that you bring her in today so that a doctor can examine her. Secondly, I need to know the tablet strength - do you know how many milligrams are in the tablets you have?

[Guy]: They're 125 mg tablets {I don't even think that 125 mg tablets EXIST, since that would be enough to treat several ELEPHANTS, but whatever}. And that girl I talked to just said you didn't have any appointments. But I could bring her in as an emergency? But that's more expensive? How does THAT work? What, do you have, like, two different doctors there, one seeing emergencies, or something?

[LIVS]: Yep, that's exactly right. We have two doctors, one seeing appointments and one seeing emergencies. The appointment schedule is full, but emergencies are seen on a walk-in basis, so you can bring her in anytime to see the emergency doctor. I'd recommend bringing her in as soon as possible, since this has been going on for days and is getting worse. And since I've never seen Effbee, I can't give you medication instructions, but if you're sure that they're really 125 mg tablets then I would not give her any more since that is an ENORMOUS overdose.

[Guy]: . . . . . . . . . . well, can I just keep giving her Immodium, but give her less? OH!!! And I also started giving her some doxycillin* a couple of days ago. She had a bunch left over from when she had some kind of infection last year. Should I keep giving it to her?

[LIVS]: {headdesk}

I doubt the guy was really overdosing the dog; he said it was children's Immodium and it's a big dog, and the only tablets I've ever seen are 2 mg. But how do you just randomly decide, all by yourself, to give your dog a drug without even knowing how much of it you're giving? And how do you think, "Well, I've been trying this treatment for days, and she's actually getting worse instead of better, but what I really want to do is just keep doing it, only LESS." ?!?!?

Needless to say, they never showed up. I really hope this poor dog just ate some trash and has some transient gastroenteritis, and doesn't have, oh, I don't know, a TENNIS BALL IN HER DUODENUM or something equally horrible.

*Yes. Doxycillin.

Wednesday, September 26, 2012

Fall as an adult

This is the first fall (except the one I spent as a postdoc, but I already knew I was heading back to school the following September so it wasn't the same) that didn't mean back to school. The year turns over in fall, for me -- both because of the academic calendar that I've been bound by for 29 years, and because I think of New Year's eve as being in October. :)

I kind of miss the thrill of a new school year, a clean academic slate, the opportunity to have consistent, regularly scheduled positive feedback on my academic progress (yes, I just said I miss exams). But it's also nice to know that when I get home from work at the end of the night, my time is my own. There are no demands on me after work (well, there's a lot I should be - and less that I am - studying, but it's semi-elective). If I want to spend a whole Sunday playing with H in a pumpkin patch, I'm free to do that without knowing in the back of my mind that I'm going to have to "pay back" that time later with late nights catching up on the work I missed. It feels free. I also feel crushingly weighted down with responsibility for patients for whom I am often the final word, and with the magnitude of the things I still don't know (or have forgotten - that feels so shameful, to have learned something and not be able to use it). And I do spend a lot of my days off studying when H is napping, or looking things up on VIN, or ruminating over things I think I did inadequately or just plain incorrectly at work.

BUT ENOUGH ALREADY, this is a post about having autumn fun with my cute baby! Why the heck am I brooding over work? I'll stop.

This weekend was AWESOME. We took H to a pick-your-own orchard about 30 minutes away. The one I always went to as a child has a big fall festival-type thing, and we took H to that one last year, and I was horrified by the number of cranky, impatient, ill-spirited parents snapping at their children. Plus the pumpkins are pre-picked in bins, and what's the fun of that? So we decided not to go back this year. I didn't know if we'd be able to find another one, and it turned out that there are dozens within easy driving distance of our suburb! So we picked one, mostly just based on hours and proximity, and headed out.

It turned out to have nice apple orchards. We picked a bunch of apples, H ate almost an entire gigantic apple by himself standing in the middle of the orchard, and looked absolutely adorable dressed in his little caterpillar jacket munching on a matching green apple. It also had a pumpkin patch! The pumpkins were mostly cut from the vine already (which turned out to be a good thing -- I never realized pumpkin vines were so prickly! I got a bunch of splinters in my finger when I touched one accidentally) and we just walked around and looked at them. H sat in front of one and slapped it gleefully a bunch of times, and then was over the pumpkin scene). We took a smallish one home, and it's sitting on our balcony. He goes out there a few times a day and pats it with his little hands. :)

They also had the most incredible apple cider donuts I've ever had. They sold out so we had to wait while they made more, and that was so lucky because hot out of the oven they were AMAZING!!! I think we ate 5 that day (they were small . . . . . . ish) and 2 more the next day. They were so much better hot and fresh; I'm thinking of going back just to get more donuts!

H loved the goats; they weren't in an enclosure that you could enter, so we just watched them from across the fence. I helped H feed them little kernels of corn that had fallen out of their feed bins onto the ground. I love the tickly way that goat lips gently brush food into their mouths!

He also loved the calf starters that were painted like jack-o-lanterns, and spent a long time going in and out of one. He liked eating barbecue chicken drumsticks at a picnic table, and climbing up and down the little step for the wooden photo things that you stick your head into (and it appears on top of a painted farmer, or scarecrow, or whatever).

It was a beautiful day. I had so much fun.

And then today is my day off, and I took him to an indoor baby gym that's 5 minutes away. He climbed around the giant foam obstacle course and played in the ball pit (I shudder to think of what lives in those things, but I don't want to be one of those parents who puts a fabric cover on their shopping cart and squirts Purell over everything every 2 minutes and won't let their children do fun child things because they're afraid of germs). And we signed up for a waiting list for a toddler gymnastics class!!! I don't know if we'll get a spot; since it's an Olympic year they're inundated with children wanting to be gymnasts, but it will be a lot of fun if we do.

We spent the rest of the day at home, playing on the floor -- I cut a door into one of the giant U-Haul boxes that we used for moving, and he goes in and out of it like it's a little playhouse. And we made some pretend soup together the other night in the big pot that we keep in "his" kitchen cabinet, and now he likes to make soup by himself. :) And he typed on the computer, which he also loves, until he picked it up and dropped it onto the floor from 6 inches in the air, which ended typing time. But he had fun. And I had fun. And fall is definitely my favorite season, and despite my work angst, this is probably my favorite fall. :)


Monday, September 24, 2012

Up the Wall

I'm now 2-3 weeks into my regular schedule at work, which consists of two 12-hour days and one 7-hour day where I am both the ICU and emergency doctor, AND see appointments (sometimes I only have 3 or 4 appointments, which is awesome because then the hospitalized patients actually get some attention, but sometimes I have 14 appointments, several emergencies, and hospitalized patients that need diagnostics and treatment plan changes during the day, and that is not an environment conducive to good patient care), and Saturday, where I work 6 hours and ONLY see appointments.

I think emergency and ICU work is orders of magnitude more interesting than annual checkup appointments and vaccines, but I have to say that it is REALLY nice to hear the receptionist page a triage nurse to emergency on Saturdays and know that I'm not going to have to deal with it.

Anyway, Saturdays have a generally calmer atmosphere overall, due to the fact that 1) most appointments are annuals or puppy vaccines, 2) there's a different doctor on emergency duty, and 3) I'm the only doctor seeing appointments so no one else is siphoning technicians away from me. But they're still busy, partly because my practice schedules 15 minute appointments for EVERYTHING. 3rd round of puppy shots? 15 minutes. Dog scratching its ear for the first time and needs cytology and a topical med? 15 minutes. First new puppy visit for clients who've never even had a PET before let alone a puppy, and know nothing about raising one and have 2 pages of questions? 15 minutes. Extremely sick dog with 4 separate medical problems, all of which need diagnostics and extensive client education? 15 freaking minutes. So it's very easy to get behind.

The more aggravating problem on Saturdays is that the receptionists apparently have no training whatsoever on how to field calls. This post was inspired by my colleague over at 2nd Career, who seems to have a similar problem. I started to leave a comment and realized it wasn't going to fit in the comment box, so I came back over here to vent more thoroughly. :)

I'm sure this happens every day, but since I'm the only doctor there on Saturday I notice it a lot more. The receptionists come back literally between EVERY APPOINTMENT to ask me a question about someone on the phone. And it's always something where I need to stop what I'm doing, close the chart I'm in, look up the patient, look through their chart, and make a decision about something. I have never been in a practice before where the doctor is expected to be at the beck and call of everyone who can dial a phone!!! The EFFICIENT way to handle these phone calls is to take a message and tell the client I'll call them back. This is made even more simple by our computerized message system, which allows reception to leave me a message with a time and date stamp under my account in our EMR system, where all I have to do is check my calls and I'll see the whole list pop up and can then work through the calls when I have time. They wouldn't even have to get out of their chair. But instead they write a note on a scrap of paper, hang out in the pharmacy waiting for me to finish an appointment, and then when I'm in the middle of writing up a record or trying to calculate a medication dose, they start talking to me about the message.

The serious risks of this habit are that I'll make a medication error (which already happened once; luckily it was both very minor and caught by my technician) or that the client won't get a call back because I lost the scrap of paper that the message was written on. But even if neither of those things happens, it's distracting, it pulls me away from what I'm working on, it takes time to deal with, and then I'm even LATER for my next appointment, which is inconsiderate of the client who has actually made an appointment to see me. So it's driving me UP THE WALL.

I don't actually have the authority to make management decisions, but next Saturday I'm going to sit down with the receptionists at the start of the shift and tell them I'd like to try a new strategy. There are 3 (and only 3) things that can happen when someone calls:

1) It's something the receptionist can handle, and then they deal with it as usual and that's the end of that.
2) The client is told, "The doctor is in the middle of seeing appointments and will call you back when she's done seeing patients for the day. It will be before 5 PM". And then no matter HOW MUCH the client insists it'll "just take a second" or they "really need an answer right now", the receptionist takes a message and puts it into my messages list in the computer and does not interrupt what I'm working on to tell me about it.
3) If it's really something that can't wait for a call back, they can come in on an emergency basis. 

That's it. Three options. We'll see how it goes.


Wednesday, August 29, 2012

Growing pains

Sometime I really like my job. There are days (exceedingly rare, but they exist) when I have just the right amount of work to do. I'm steadily busy all day, I get to pee a couple of times, I may even get 10 minutes to eat my lunch while not working, and I get each emergency that comes in squared away before the next one arrives. I really like those days.

Most of the time, it's either slammed or dead. On days when it's dead, I read about cases. I'll look back through the schedule to find emergencies that my immediate supervisor (who is a little overbearing and a total micro-manager, but a very solidly good clinician) saw and go through the file to see how he approached the case. I'll skim message boards on VIN. I'll look up topics on my perpetual checklist of things to study in critical care or internal medicine textbooks. I'll work on my personal formulary. These days are fine; by 2 PM I do really wish that an emergency would come in so I'd have a patient to work on, but there's a lot of stuff I need to study so it's not like it's wasted time.

On days when it's slammed, I feel like I'm frantically treading water and my head keeps going under. I don't like those days. I have several weaknesses from a case management standpoint: I don't delegate enough to nurses. I worry too much about spending clients' money unnecessarily on diagnostics, so even if they approve 4 tests, if one of them kind of depends on another, I'll wait to get the results of the first one before I make a decision about whether to do the other one. The nurses hate that; they want to take the patient back, do all the diagnostics, and put the patient in a cage so they can move on to the next case. Usually they end up moving on to the next case while I'm waiting for results, so then I end up with no one to help me if it turns out I really do need to do another test. I'm also very afraid of missing something, so I look things up a lot. I look up differentials, I look up other diagnostics that I think might be indicated, I look up treatment alternatives. I write discharge instructions that are more thorough than they need to be, probably. They're by far the longest discharges I've ever seen at this hospital. None of these things that I do are strictly NECESSARY. I would probably still be an adequate clinician if I stopped doing all of them cold turkey tomorrow.

Part of the problem is that we're trying to grow into a major referral center. So for a lot of the cases that a typical GP would see and say, "Well, let's try a few days of Rimadyl and do rads next week if Spot isn't better", I feel compelled to recommend radiographs right now. Bloodwork in case there's a kidney or liver problem, before I start an NSAID. A FULL physical exam (including otoscope, ophthalmoscope, orthopedic exam, thorough auscultation of the heart and lungs, rectal exam, etc). I see some clinicians go into a sick appointment and only examine the body system involved in the primary complaint! The rest of the dog doesn't even get touched! But really, if you have 15 minute appointments for 3 hours straight, that's probably the only way to fit them all in.

So, I'm having a really hard time trying to balance thoroughness with efficiency, and pragmatism with the pressure of being the referral practice. I feel like if I were a busy GP, I would see a case and come up with a plan, and then if it didn't work and it were going to take me 2 hours (that I didn't have) to research what else I might need to do, I could refer it. Here, I'M the person that people are supposed to be referring TO. Which is kind of absurd, given that most of the referring vets have years of experience and I've been a doctor for 4 weeks. That's just silly. But we're trying to build a referral practice. So far I've only seen one case where I felt like it would be acceptable to the administration for me to refer it. It was a complicated case that would have been a good internal medicine patient, and I tried to get them to go to the university. But that's the only case where that's been true.

I guess my real problem is that I feel a lot of pressure to be faster (and I realize I'm unreasonably slow, even given the fact that I've only been actively practicing for about 2 weeks since I spent a couple of weeks shadowing other clinicians). But I also feel pressure to practice almost academic-level medicine. And I don't think those two things are physically possible to have simultaneously. And if I have to pick being a thorough clinician who's slow, and being a fast clinician who practices substandard medicine, of COURSE I choose being thorough. And I know that some of this will just come with experience; I'm still at the point in my career where very nearly everything that I see is the first time I've ever seen it. At least as the primary clinician; I may have seen it in school but that's a totally different experience. So I have to look a LOT of things up. Once I've seen it a couple of times, I'll have the experience of what I did the previous time and how it worked out, to draw on, and I won't need to spend half an hour on VIN before I make a decision.

But for now, it's frustrating. Both to be so slow, and to feel like the nurses and most of the other clinicians don't understand that part of my slowness is being thorough, and part of it is simply a lack of experience, which will be self-correcting in time.


Wednesday, August 22, 2012

Sucker

What has two thumbs and is a giant sucker? This girl!

I got my first surrendered dog last week.

Two weeks ago, I had a very sweet and cute 5 year old Great Dane mix who presented on emergency with hemorrhagic diarrhea and a really out of control (but likely totally treatable) skin condition that was cosmetically appalling (and very itchy). And her owner had no money to spend on diagnostics or treatment, so I made the best plan I could with her financial limitations and gave her a very good prognosis with the normal plan and a decent prognosis with the bare bones plan. I think it was 100% worth trying to treat her at home for a few days and see how she did; she was still eating and alert and I really think she may have done wonderfully and had another 5 years ahead of her. But her owner wanted to euthanize her. I tried to talk her out of it, and she played the trump card of, "If there's a chance this could be something that could infect my toddler, I can't take the risk of taking her home". And although that was pretty unlikely, since she wouldn't let me do ANY diagnostics, I couldn't PROVE that it wasn't. She also had lost an alarming amount of weight in the past 6 months without any dietary changes, which raised my suspicion of neoplasia, so after a lot of discussion with her and my concern that it was potentially unethical (and possibly legally indefensible) to send her home after the owner voiced concern about infecting her son with something (it could have been Salmonella, or Giardia, or some other zoonosis), with enormous reservations I agreed to euthanize her. I got the impression that the owner was not that emotionally invested in her and was ready to be done, and I was worried about her quality of life with the owner even if she recovered from the GI problem, especially given the (very preventable) skin issue that the owner had allowed to get ferociously out of control. She clearly was not a well-cared for dog.

But I do not feel good about the decision. I'm not sure what else I could have done; I couldn't force her to take the dog home. I felt that with the hemorrhagic diarrhea and the skin problems (and the sheer size of the dog) that it would be difficult to find an adopter quickly even if I could convince the owner to surrender her. I couldn't possibly take the dog home myself; with my psychotic little Bug I'm unfortunately never going to be able to bring another dog into the house. I couldn't afford to board the dog at work for the weeks to months it might take me to find a foster home or adopter. And the weight loss did worry me that something very serious might be going on.

Even with those considerations, though, I think about that dog at least a dozen times a day and feel terrible for euthanizing her. I feel like it was a convenience euthanasia, that the owner seized the opportunity when the diarrhea began to use that as an excuse to get rid of a dog she no longer wanted. And I feel terrible about that.

Anyway, it's done, and I can't undo it. So last Friday, I had another dog come in. This one is a tiny, cute little 7 year old chihuahua mix (who is very sweet and calm and not chihuahua-like at all) and had been in a fight with a stray dog. She had some lacerations that needed exploration and repair, and the owner declined the estimate and asked to euthanize. So I said hell no, I'm not euthanizing this dog (to myself, not the owner), and came back with a minimal plan (the lacerations really looked like they would need drains and surgical debridement and suturing, and the minimal plan was clip and clean, antibiotics, rabies booster, bandage, carprofen, hope for the best) and she refused THAT. She really wanted to euthanize. We discussed it for a long time and I couldn't persuade her, even when I pointed out that we could at least give her a CHANCE and see what happened, and she could always euthanize in a few days if the dog wasn't getting better, whereas if I euthanize her I can't take that back. From my perspective, there was no downside to trying conservative treatment before deciding to euthanize. But she wouldn't do it. So I made the euthanasia estimate as expensive as I possibly could (it ended up being more than the conservative treatment plan) and then offered her the alternative of surrenduring the dog to me, in which case the medical bills would become my responsibility and she wouldn't have to pay a dime. She jumped on the offer, and I now have a chihuahua!

Some of the staff were laughing at me a little, saying I'm a sucker. Which is totally true. Part of me suspects the owner played me. But she really would have euthanized this dog, and I was absolutely not going to do that again, not after the Great Dane two weeks ago. So, I may be a sucker, but at least I'm a sucker who can face myself in the mirror. :)

And my sister has a couple of friends who are interested in meeting the dog. And a cute, sweet, healthy little 12 pound dog is not that hard to find a home for. So all in all, whether I got played or not, I am extremely happy about this decision. :)