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.

1 comment:

The Snowboarding (and Crossfitting) Veterinarian said...

The speed will come with time, as you said. It's so hard when every single case is new! I feel the same way with exotics cases - ugh.
On the other hand, it probably beats seeing the same thing all day every day (like itchy skin)!