Grateful for my Feet

Growing up, I didn't like the look of my feet. They reminded me of my Dad's feet. Mom's feet were so feminine and nice looking. Somehow, my Dad's genes reigned strong on this trait, for me and my siblings.

Dad would say, "What's wrong with your feet? They look like mine and they're fine, strong feet". I wasn't able to see what he saw until many years later. He was so right; these feet are just fine. Think of all the miles they've carried me and they still look OK.

Feet can be timeless (note: can be). If all you see is someone's feet it can be really tough to predict their age. Truly young feet can look old and vice versa. My Mom's feet maintained their youthful, feminine look up until the day she died at age 93. Amazing. Amazing feet.

As an aside, two days a week I ply my trade as a kidney doctor in the Podiatry clinic in our Federal Way location. When working at a remote site, you take whatever space is available. At first I was off-put by the anatomic posters of feet on the walls and the three dimensional models of ankle and metatarsal bones. Now I've come to appreciate my home-away-from-home in the foot clinic. The podiatrists are an interesting group; I've grown to enjoy their company and enjoy the  fact that we work and think from such different perspectives. Vive le difference.

What makes me chuckle is listening to my podiatrist colleague dictate outpatient notes. He describes in great detail things that sound incredibly gross....

"......the severely mycotic ram's horn toenails..." brings to mind these images. I've seen them frequently and fail to understand how something like this takes hold in the first place. I could always ask my podiatrist friend. From the number of those afflicted, clearly this is bread-and-butter business for him.

I'd best not be smug. When I'm old I may not be just wearing purple; I may be sporting these However, if I continue in the path of  my 95 year old Dad, I won't. Thankfully.

"He Went to Chicago...."

During medical school and residency, slang phrases for death were inevitable, especially amongst the surgical trainees  Thinking back, I'm wondering if a certain wild and crazy resident from Argentina named Mario K might not have invented his own terminology for the act of passing on into the great unknown. I first heard the phrase come out of his mouth and then from others who worked with him. After leaving Texas and my training roots, I never heard this expression again. A Google search for synonyms for  the verb "to die" spews forth all manner of  crude expressions as well as the more generally accepted phrases that one might hear from a funeral director....like "departed", "passed away", or "left us".

Mario referred to the act of dying as "going to Chicago". I remember coming in for rounds one morning as an eager, yet terrified third year medical student and hearing him (as senior surgical resident) say of someone who had died during the night, "He went to Chicago".  I recalled thinking this an odd blend of disrespectful, weird, and funny, a not uncommon situation in Medicine when stress-busting humor commonly borders on the edge of decency, if not beyond. Medical types typically limit our not-so-professional-speak to times when we're in the company of others of like mind or those who wouldn't take offense. Discretion is key.

Yet, "going to Chicago" isn't really an offensive term for dying. The only question I had then, and still do is what happens if someone dies in Chicago?

**also posted at Back in the Day

Another On Call Week Bites the Dust

Praise God; the on-call week is over. 7 days (this always impresses my Dad but no one else, particularly) carrying the pager continuously and rounding on the hospital service is rather like banging your head against the wall. It feels so good when you stop. Ahhh.

This week wasn't too rugged; every on-call week spins a different feel. One new kidney transplant, a number of people in house with transplants from past days, and the usual collection of dialysis patients as well as those whose kidney function had been good but then turned south. All in a week's work. 

I felt good about hitting a controversial diagnosis "on the head", spot-on, and recommending a treatment that actually worked and worked fast. Those wins are terrific when there is so much we nephrologists do that feels like applying pressure to an open, gushing wound.

And so, on this Monday, my weekend begins. The sun is shining in Seattle. The trash, recycling, and yard waste pickups (another of my favorites: the triple header) passed by our house this morning. All is well.

Only wish I wasn't dreaming about a tall stack of blueberry pancakes, dripping with melted butter and real maple syrup with a side of crispy bacon.

Of Mammography Suites and Anxiety

The Breast Center (aka mammography suite) at the clinic where I work is a lovely, modern and thoughtfully designed facility. Just inside the door is a small waiting room for those accompanying their  wives, girlfriends, mothers or friends to the procedure. Next is the registration desk, offset from the waiting room to preserve privacy. From there, the woman is escorted back to the dressing room area, given friendly, well rehearsed instructions on how to don the gown after undressing from the waist up and where to put the valuables. There are doors with locks on the well designed adjacent wall. The key attaches to a flexible pink plastic wrist-let which is worn into the inner sanctum, as I like to call it. This tastefully adorned room just for women-in-waiting invites. Lovely, comfortable chairs, soft lighting, and lots of magazines welcome the weary if not the slightly anxious. There's barely a sound to be heard.

And then, the summons. My turn and I'm led back into one of the exam rooms. Today I read the name on the machine: "Mammo-mat"; the vice that flattens that breast into a pancake. Nice. I've never seen the same technician twice in all these years of repeated mammograms. This one was prompt and efficient, going about her work with intention and care but little humor. Of course, she may have been reacting to my vibe which was serious and stoic.

Four views, two on each side. The images populated the screen within seconds and the technician showed me the pictures. I haven't a clue what's OK and what's not OK. I don't ask what she thinks much as I'd like to. She'd say she couldn't comment, I'm sure. I'll have to wait for the formal reading.

And then, it's over. Reverse order: past the inner sanctuary with other women quietly reading magazines to the re-dressing area and around the corner to the reception desk and out the door. I'm done. Slowly the anxiety creeps in. I feel it in my upper arms and shoulders, a tightening refusing to relax. Try as I might to divert my attention, the physical sensation will persist and my mind will periodically be pulled from the present moment to the future, the what if? question.

Two points:

The mammography suite has become an art form over the years; moving from a meager extension of the existing department of radiology to a distinct entity. Privacy is respected. No longer do women sit out in an exposed waiting room where the world walks by and the sign above reads "Mammography Department". The inner sanctum resembles a spa. If I weren't so edgy, I'd want to stay there all day and read magazines and ponder life, maybe with a glass of Sauvignon Blanc at my side.

Secondly, I can't escape the escalating anxiety over the results. The waiting time is short, way shorter than most women wait to learn of their results but I'm a gal that wants most things NOW. Once I get the good news, all that tension is history and the mammography suite evaporates; until next year around the same time..

Good Bye to On Call Week

Ahhhh, sweet Monday. She comes again but none too soon. The past week was rugged. My sign out to the good man taking over for me today started with two admonishments:  OMG and LHM. What's LHM you ask? He didn't know either. "Lord have Mercy"; a good southern expression.

This is December 19; eeeeech! I've got so much to do and would much rather write blog posts, watch TV and read.The tree is up but bare. The house is a mess.

My on-call week, the last for the year 2011, logs into the memory bank; soon forgotten as part of the steady stream of sameness with a sprinkle of the unknown and  the unique.

This was the week of opposing forces in medicine. By that, I refer to Kidneys vs Heart or Kidneys vs Liver; wicked battles where the requirements for optimal function of one organ stand in direct odds to the requirements of the other. These so called cardio-renal syndromes or hepato-renal syndromes invoke a cringe and dread because good treatments and outcomes are hard to achieve. The best we can hope for, in my opinion, is self-healing. I've never convinced myself that anything I do except "stand by" results in anything other than muddied waters. Sigh.  The week was unusually laden with examples of organs at civil war.

Louisa Lung, Harold Heart, Katie Kidney and Larry Liver

"Why can't we all just get along?", I wonder.  Something like this, maybe....??

Typing Skills

My Dad was ahead of his day. As school superintendent of the Lago School in Aruba, he insisted that every student learn to type. Mind you, this was back in the day when typewriters looked sort of like the one below. This was also the time when young men launched into careers that had little to do with typing skills whereas women, be the teachers, clerical staff, or housewives benefited from knowing how to type without looking at the keys.

My brother learned to type in high school in Aruba and when he went away to college he was a hot ticket amongst his peers who asked him to type up their papers and reports for class. He earned money by the page. He's still a pretty good typist, probably far better than other men his age.

Hands down, typing was the best skill I mastered in school from the perspective of continuous utilization.  Knowing how to type fast and with accuracy paid off. Countless hours saved. Time is money. More time makes way for more rest.

These days we think nothing of younger folks pecking away at their computer keyboards. I'm not sure how people learn to type these days; probably either  entirely self taught or with a typing tutor on line. The learning starts earlier and earlier; I'd predict many begin as grade school students if not before. In Aruba, back in the late 1960's we learned the 'old school' way where the keys were covered over with heavy duty tape.  We learned to touch type as opposed to the "search and peck" style I see some contemporaries of mine utilize.

Although typing wasn't a necessary skill in Medicine until the early 1990's when email hit the scene, everyone in the field depends on the skill nowadays. The electronic medical record, a prime example of how medical documentation changed in the past ten years makes my point. We type constantly; clinic notes, communications, emails, and other updates fill the gaps between seeing patients. Many of us bring work home in the evening; although this may involve dictation, typing is more common.

Typewriters are a thing of the past except in the lives of  'eccentrics' or the technically challenged. Who among us is not a slave to the keyboard?

I'm grateful that my Dad, who at one time practiced his skills at the typewriter, who encouraged all of his students to get into that typing class. Now.

This post is also published today at Back in the Day.

A New Blog Launches

On the first anniversary of my Mom's death, 10/12/11, I launched a sister blog to Ahead of the Wave. Weeks back, I wrote about an idea for a new blog.

The flash of inspiration required development,  a time to gestate and morph into something more tangible in my mind. I began by focusing on the design of the blog, spending hours composing the description, the dedications, not to mention the font, colors and layout of each page. Behind the scenes, I reflected on the theme of the blog, extracting memories from decades past and considering how I might write about them. There were several weeks when I had no time to consider a second blog and longed to surrender the entire idea. I worried that there wouldn't be adequate material to support a new blogging adventure. I stressed over writing about topics that might offend others or institutions. But, the idea and the desire wouldn't leave me alone for long.

I composed a few posts for the new blog and held them back in the archive. Several days before the first anniversary of Mom's death, it occurred to me that Mom would have emphatically supported me, "Go for it.", she would have said. Don't wait. Writing was one of  Mom's passions, a talent she put on the so-called back burner for a so-called rainy day and ultimately to her (and our) great disadvantage. In the meantime, she grew older, allowed herself to be distracted by other less important tasks, and let her great gift for written expression melt away. Although she made so many wonderful contributions in her life, I sincerely believe this was a gift of the written word was left unshared with the world.

As I think about Mom, I realize: the time is now, So what if I've written only a few posts? There are dozens brewing in my head. If I just let go and move forward, the momentum will sustain me. The reality of clicking the publish icon on the blog means Go. I could feel Mom's support everywhere and still do.

Back in the Day is a blog about my personal reflections; big and small, serious and humorous, critical and inane, on my life in Medicine. Although I may be inspired by specific experiences with patients, I will protect their anonymity. My focus is more personal; what I was thinking or feeling at the time and how experiences changed and influenced me. Written in random order, jumping from era to era (a span of 40 years), there's much to tell from my first thoughts of a career in medicine at the age 17 to where I stand right now, at the age of 57.

Thanks for checking out Back in the Day.

Back in the Day.....

A great idea percolated into my consciousness today, built on the frame of a single thought leading to the next and then the next. Isn't this the way these mysteries unfold?  I suppose very creative people experience this wonderful excitement on a regular basis. I do not and this makes what happened today all the more significant.

I drove along 5th Avenue in downtown Seattle on my way to the E.R. to spend the day with my Dad who took sick with a febrile illness today. My thoughts focused on things medical; like the modern efficiencies of our hospital's emergency facilities. The next thought took me to the norm of professional "back in the day"; not just 30 years ago or 15 years ago but even 5 years ago. "Back in the day", the concept of remembering and revering the way things were in that great place we call the past. All that changed (the operative word); the processes, the cultures, the styles, the beliefs, the way we did things and the ways we thought. And, the adjustments we made, myself individually and the profession collectively struck me as enormous and furthermore important.

Have I completely lost you?

In the midst of all the musing I thought about a 16 year old girl considering a future in medicine to the almost 57 year old seasoned physician,  I thought....wow, all these snippets of memories, my experiences, my fears, my achievements, my failures..... all the bits and pieces that make up the whole.Perhaps these are of little interest to readers. Perhaps they will be. What's important for me is the writing. The memories need to become words on a page. They must.

In a moment, the idea gelled. A blog, an over the shoulder backward look, written as single posts but part of  complicated whole. I envision nothing chronological, more of a crazy quilt. Also, nothing specific about patients; we medical bloggers must protect confidential information. Nothing overly sentimental. These swirling, every recurring memories need a forum. I know what to do: Blog.

The title...Back in the Day. A personal retrospective.
Ahead of the Wave remains intact, my present moment.
Back in the Day honors the past. Stay tuned.

(Some) Mondays are So Sweet

Oh my, what a wonderful day!  Monday. Monday. Monday.  This day, carries a shroud of doldrums for many as the start of the traditional work week. But, not for me. Monday is my day off.

Today is particularly sweet as the official close of a a seven day "on call" roll; a time of frenzied ups and downs, a breath here and there, dozens of phone calls, and hundreds of decisions big and small. Do this, do that, coupled with a healthy dose of questioning: did I make the "right" call considering all the variables and choices?  Go with it, get behind the decision and move forward, monitoring for a need to shift gears and move in a new direction. Change, volatility, change, uncertainty, change, surprise, change and unpredictability. By week's end, I feel ready to bask in the glow of no more responsibilities, at least for awhile.

Last night, pumped on caffeine, I was wired until after eleven but knowing I could sleep in today I didn't care. A last buzz of the pager at 5:30 AM reminded me the work continues consciously or unconsciously until the clock slips past 8 AM. Back to sleep until the bright morning sunshine and the low rumbling of the recycling truck awakened me several hours later. Sweet, sweet sleep and then the realization that there's nothing on the agenda today except for things of my choosing.

I liken this feeling to banging my head against the wall; it feels so good when I stop.

Are Patients are Still Patient(s)?

There was a time when doctors were doctors. Now we are providers.

There was a time when office assistants were just that. Now they are clinical service representatives. No, wait; that was last year. Now they are flow managers. Whaaaat?? Providers need managers to keep them efficient, on time, and on task.

The emergency room used to be the ER, now it's the ED (emergency department). Renal failure requiring chronic dialysis used to be termed, ESRD (end stage renal disease); now we acknowledge this diagnosis as CKD (chronic kidney disease) and there are 5 stages depending on severity. Cadaveric renal transplant (CRT) donors morphed into deceased donor transplants (DDT).  Non-heart-beating renal donors adopted the new terminology: delayed cardiac death (DCD) donors. The blood bank is now transfusion services.

Countless changes in terminology reflect some modern sense of political correctness, I suppose.

The constants?  Patients are still patients. They may not always be patient in demeanor or attitude but then, they never have been. At least we are not referring to patients as clients. Yet.

Messed Up

This morning I fall into a 7 day on-call rotation for the hospital service. Dread. Exhaustion. Seemingly endless issues which have no permanent fix. Nothing I do is like taking out an inflamed appendix in an otherwise healthy person and meeting up with a cure. Nothing.

I'm strangling.

All I can do is give my best self to this job, come home and vegetate, sleep,  get up and go at it again. Over and over.

There is no energy left over for blogging, gardening, nurturing relationships, exercising.

Triathlon?  Out the window.

My depression is overpowering me. Again. Never ever does it go away forever despite my hopes and creative pharmacology.

For weeks I've felt this way. Can't shake it.

And so, I cut back, eliminate, and ruminate. My life is WORK and my DAD in that order. And, downtime....on the couch watching TV, eating, reading, trying to regain some energy to start it all up the next day.

For now, blogging is on hold until I can get out of this mess. Again.

Wet or Dry?

You'd think distinguishing wet from dry would be straightforward. All you need do is open your eyes and take in the view. The extremes of wet and dry paint unmistakable pictures in our brains. Even less dramatic images than these provide a fairly accurate interpretation of what is and what isn't wet or dry.

 

Did you know (medical types will agree with me; I hope) that distinguishing wet from dry in medical practice is likely the most challenging day to day dilemma we face?  After over 30 years of  "doctoring" and sub specializing in a field where making this distinction between wet and/or dry is of critical importance, I'm eternally humbled. Seems I get it wrong way more than I think I should. Sometimes in the midst of emotional exhaustion after a week on call, I consider my decades of experience with thousands of patients worth very little when it comes to making the call regarding the fundamental question: wet or dry?.

Why is this seemingly straightforward diagnostic decision so difficult?

I'll take a stab at it answering this question. I certainly had my head buried in the problem all week as the hospital consultant for the Nephrology service.

The problem is:

1. Too much fluid (wet) and too little fluid (dry) is relative.

2. What is too much for Peter may be too little for Paul. What is too little for Mary Kate may be too much for Ashley.

3. The physical exam gets you only so far; someone can be "swimming" (as I like to say) in water but be dry where it counts (perfusion of critical internal organs). The flips side is a physical exam with relatively normal findings with regard to fluid but meanwhile the wet is insidiously attacking the one organ that can tolerate it the least, the lungs. Wet lungs are never a good thing.

4. A little wet can turn deadly wet just because. A little dry can turn deadly dry just because.

5. Treating dry with fluids can easily turn sour. Treating wet with drying agents (diuretics, dialysis or other physical removal of fluid) can easily turn sour. Why? Just because.

6. Wet may be just what the doctor ordered to fix the problem. Dry may be just what the doctor ordered to fix the problem. Sometimes it's best not to intervene at all but let the wet or the dry just be and wait it out. But, all too often we try to fix the wet or the dry and that leads to issues that further compound the problem.

Last evening, after a long 7 day on-call stretch, I had had it up to my eyeballs in this morass of fluid, slogging my way through the wet and dry fields and making decisions based on gut feelings, experience, and a small dose of science. I get it wrong as often as I get it right, I thought at which point I lamented to my husband that I really don't have what it takes to do this kind of work.

His comment?


"Who do you know that gets this wet/dry stuff right? Anyone?"

The answer is that no one gets it right all the time or even most of the time. We all try. We genuinely try our best but the pathophysiology of each situation; the time, place and person, the unique moment creates a minefield waiting for a misstep.

I'm glad the week is almost over.

Tough Week

Dead and fallen branches, hard and slippery rocks close to a stream. This was my week on call. The end is in sight.

The End of a Bust-Ass Week

I'm plowed under; emotionally and physically beat. This has been a butt of a week.

I'm beginning to feel as though this so-called 0.8 time is a joke; it's every bit full-time by the hours and probably more. I'm off on Mondays but Tuesday-Friday I'm working 8-9 hours with 2 hours plus on the computer at home every evening cleaning up work that I couldn't finish while at the office. Paperwork is strangling me or better said, computer documentation is claiming my life, infiltrating into my home time, my me-time and on and on.

Complain, complain. Yes, I'll complain.

We're short staffed at work; there are too few doctors for the volume and complexity of our patients. We're short staffed with office personnel who seem to be calling in sick regularly. Today I had another migraine headache; my third this week. Pop an imitrex and get to work. Go. Just. Do. It. It really bugs me that not all on our team share in the work ethic and think nothing of leaving us in the lurch to make do without them. Call me intolerant, demanding, and wed to unattainable ideals of teamwork. I am. That, I am.

I've seen so many patients this week they're blending together, their complexities and individual issues jumbled into a ball of pain. Once dictated, the details implode. Thank goodness for a medical record. I have to remind myself to never, ever walk into an exam room "cold". The prior notes need scrutiny or else the first five minutes of the encounter is me trying to cover up my confusion and seeming lack of sharpness. I cover well but inside the landscape is really scary.

I've got the next three days away from work. Can I keep myself disengaged or will there be this insane and unhealthy pull to log back on and work remotely, to get ahead of the wave of work coming my way next week? Oh, my God but I'm weary.

The problem is....once I get a bit of time away from work, my focus shifts to my Dad and his social needs. He needs me to visit, to be his daughter, to take him to church, to just be there for him.

I'm strangling.

Meantime, I'm trying to get in shape for the Triathlon. That's a good thing because whenever I can drag my sorry ass through a workout, I feel better instantly.

Where's the balance? How can I navigate this terrain without as we say, "shorting out" big time?  I've been there, done that and it wasn't good.

I'm trying. I'm trying.

What I Heard

Another busy work week passes; only three days in clinic but it felt like five. This 80 percent time is a bit of misnomer. This work is full time when you throw in the extra hours put in at home on line and the every fourth weekend on call in the hospital. So far, my head is above water and ahead of the wave. The satisfaction/enjoyment outweighs the fatigue/frustration.

Last week I wrote about comments made to patients. This week I'm remembering what some patients said to me.

"I'm just glad to be alive."

"My husband is 90; he's still going to work. I thought when we got in our eighties we could relax and travel more. Plus, our two daughters live at home." (my jaw dropped).

"Doc, this one here is my baby, not my grand-baby (showing me a photograph); she's 18 months. She came along after my transplant." (grin). [this quote from an older man....]

"I have to apologize for missing my last few appointments and for being 45 minutes late today. Chalk it up to irresponsible behavior ever since I retired."

"Your right doc, I've been in some hell holes in my day, real hell holes; ya know what I mean?" [this quote from a veteran who served overseas...]

"I promise I'm not going to cry today. I brought her (a friend) along to keep me calm."

"Choices. Choices. I'll do whatever you suggest. You know best." (not so sure about that...)

"My goal is to weigh what I weighed before my transplant by the time I turn 60. Can you look back and see what I weighed right before my transplant?"

"My doctor sent me to see you because she said I had kidney failure. She was supposed to send you some records." (sigh)
 
And the award for the week?

"What can I do to increase my creatinine level?" 

For the non-medical folks, the problem is a high creatinine level; a marker of kidney dysfunction and/or outright kidney failure. No one should ever, EVER want to increase it although I can tell you ways to do so. Fortunately this is a very easy question to answer.  I love an easy question since most are gnarly and laden down with opinion, qualifiers, and best guesses.

Stability is Sucess

Things I remember saying to patients this week......

"You've grown a lot of different bugs in your urine at various times; look here....I'm seeing Klebsiella, E. coli, Enterococcus, Staph coagulase negative, Serratia. You're an equal opportunity hostess."

"Your kidney function is better this time; not exactly sure why but we don't ask questions when things improve. We just take it."

"Your kidney function is relatively stable, some wobble in the lab results visit to visit but overall stable. Stability is success." **

"Yep, you've got me today. I know you weren't expecting to see me on a Monday but one of our colleagues is out sick and they called me in. So....you've got me!"

"I don't think you've got polycystic kidney disease but we need to do a few additional tests to find out for sure."

"Do you have obstructive sleep apnea?"  (the answer was almost always, affirmative....what an epidemic of people with sleep disordered breathing)

"You've got 35 percent kidney function; that sounds awful but I wouldn't expect you to have symptoms at that level. Your kidneys are doing a pretty decent job of regulating your electrolyte, acid-base balance, and fluid balance. But...."

"You use mostly sea salt?  That's basically salt."  (sigh)

"Your kidneys are scarred from diabetes and high blood pressure. Like a scar anywhere on the body it's going to be there forever. We can only hope to slow the process down and prevent further scarring."

"You've got overactive parathyroid glands; that happens to almost everyone with chronic renal failure. Parathyroid glands are in your neck but they have nothing to do with the thyroid which is also in your neck."

"Your dialysis fistula is beautiful, just beautiful."

"We really need to get that tunneled chest catheter out before it gets infected."

"I know you aren't keen on adding any more medication but your blood pressure is dangerously high."

"It's all gravity driven. Totally. During the day your swelling collects in your lower legs as you are upright. At night it layers out in your back and buttocks (or butt, depending on the patient) and your ankles look good when you wake up. The swelling hasn't really gone away, it's just redistributed."

"Do you think you can cut back on your dietary salt intake?  Any room for improvement?"

All in a week's work. Over and over and over again. With twists thrown in at the oddest times, lots of laughs, and empathetic acknowledgments.

** My favorite phrase when I talk to patients with chronic kidney disease who are not yet on dialysis. When their kidney function remains roughly the same, I count that as a win. They always hope for improvement and sometimes we get that but gradually many are accepting what I say about stability being success.

It's a Disease

I'm concluding that my lapse in posting this month is a direct result of a more intense schedule at work. Kicking it up from 0.6 to 0.8 full time equivalent is apparently a bigger incremental increase in time than I'd predicted. It feels like a lot more and for all practical purposes is a full time proposition by the time the hours add up; well over 40/wk for sure. I shouldn't whine; at least I'm gainfully employed and valued by those who pay my salary. Plus, I have great colleagues.

I find myself perpetually connected to my work. I find it impossible to stay away from my computer link to work on days off, weekends. I rationalize by telling myself that I'm just getting "ahead of the wave" of work that will stack into deeper piles if I don't whack it back. Instead of batching my work and taking a chunk of time during my work day to tackle it, I am irresistibly  tempted to just do it now so I won't have to do it later. True: my inbox is manageable but only because I'm constantly sweeping it. Curiously, the inbox is less of a physical entity, although it is that too. The inbox is all the stuff I can knock off from home on a laptop wired into my office. Mixed blessing, this.

With discipline, I suppose I could keep myself from logging on but to not do so makes me ANXIOUS and what do we do when we are ANXIOUS?  We do what needs to be done to ease the feeling.

It's this whole "ahead of the wave" business. My blog does not carry the title on a whim. It's me...it's how I deal with so much in my life (but not all; some weird exceptions) Seriously. I hate surprises, curve balls, stuffed in-boxes, and disasters that might have been averted had I only been connected.  T'is a disease. Truly. One I can see but feel powerless to tackle. Not sure I even want to change my modus operandi.  My methods work....until I hit the wall at 100 miles an hour. Having been through that once 5 years ago, I need to learn from past experiences.

The Way it is...at Work

Several months back we four kidney docs decided that for sanity's sake, we would upend the way we've traditionally divided our "work" (that would mean the clinical load: outpatients and inpatients). For years we operated a practice that had each of us following patients in the hospital as well as putting in a full day's work in the clinic seeing outpatients.

The system worked well with the hospital and downtown clinic rolled into one, large self-contained unit. Fortunately, our practice has never required us to jump in the car and drive to other hospitals to round/consult on  inpatients. However, several years ago, our practice model fragmented as all of us took on responsibilities at satellite clinics around town.  We kept the one hospital model but traveling far afield became the norm. One of my colleagues flies on a (teeny tiny) plane to a site on the Olympic Peninsula several times a month. Glad that's not me (sigh). The rest of of have a more civilized ride on the freeway to one of several free standing clinics. Our patients are delighted to see us at a facility with FREE PARKING and closer to home. Good for all. Probably.

What happened was that the combined hospital/clinic work inherent in the downtown practice became insanely heavy. Urgent hospital issues would disrupt the flow of clinic appointments as we struggled to be in two, even three places at once. We'd find ourselves hopelessly behind, covering our duties in both clinic and hospital. After several years of escalating tension around this annoying issues, we re-booted the entire system.


We now have one doctor assigned to  hospital duties and the other three are here, there and everywhere: they could be enjoying a much needed vacation or, more likely are seeing outpatients in any one of our four locations. The only problem is: we have to have at least two of these three docs in the downtown location. Why? Because volumes are highest downtown and the acuity/complexity scale is often ramped up to the max. Patients with a recent kidney and/or pancreas transplant require detailed review and can wind up back in the hospital in nothing flat.

There-in lies the problem. With docs scattered to outpatient locations separate from what we call the "mother-ship", satisfying the two doc rule and simultaneously allowing for an occasional day off or a vacation is challenging. Whereas we used to decide on a vacation a few months ahead of time, now we need to get vacation dates on the calendar 6 or more months in advance. Case in point: I just asked for the day after Thanksgiving off last week....how far down the road is that?

So, while our new model of care has some advantages, we've also learned that we need another doctor. Desperately and yesterday. We're recruiting but it takes a long time to find the proper fit: someone who will bring clinical expertise and commitment and yet have a bomb sense of humor and ability to play well with others. So until then, we work long days and feel like we're never finished. I speak for myself, I suppose although I do hear my colleagues making similar comments.

Medicine is a harsh mistress.

I'm still savoring my Monday's off. As the only one of the four who is "part-time", I've managed to keep a grip, although slipping some, on a life.

Why I Might be Tired this Week

Yesterday a patient said to me, "Doc, I feel like I've got one foot in the grave and the other on a banana peel".
We laughed together but then got serious.

The sad thing is, most every patient I've seen this week could have said the same. It's been a long, soul-draining journey through these last four days. I'm weary.

Thank goodness for the weekend.

Achieve in 2011

Prompt for Dec. 28: Achieve. What’s the thing you most want to achieve next year? How do you imagine you’ll feel when you get it? Free? Happy? Complete? Blissful? Write that feeling down. Then, brainstorm 10 things you can do, or 10 new thoughts you can think, in order to experience that feeling today. (Author: Tara Mohr)

Well now, there are lots of things I'd like to achieve in 2011 but it would be hard to pinpoint what is most important so I'll pick one and go with it......I'd really like to make peace with my work schedule. I'll be ramping up the hours in 2011, at least for the first half of the year and perhaps longer, 80 percent rather than 60 percent time.That's at least a full time schedule in my world with the every fourth weekend on call duties thrown in the mix. I'm hoping I can:

1. keep from exhaustion and burnout (I've been there and done that),.
2. accept that the work is never done,
3. pick my battles,
4. reduce the piles of paper on my desk,
5. start a little earlier, finish a little earlier,
6. try NOT to take a ton of work home,
7. resist the urge to deal with every issue right now,
8. stop for lunch, walk around a bit, stretch, and breathe
9. drink more water, and
10. cultivate tolerance, forgiveness, and trust.

Tall orders these. But, I shall try.