A Country Doctor Writes:

Fresh back from almost back-to back oceanside beach vacations with my significant other, I feel called to write about being on vacation as a physician these days. But first, we had a great time on Old Orchard Beach during Fourth of July week with her siblings, all older than we are, and then in Bar Harbor with my children and grandchildren to celebrate my birthday.

Large healthcare organizations often have many different “service lines”, some acute and 24/7, some totally prescheduled and elective. But they often end up with the same personnel policies and benefits across the board. Because of this, I ended up in my previous job having to budget “PTO” time or else not get paid for Christmas Day, for example, even though my clinic was closed so there was no way for me to work that day. And in my current job, I forgot to ask for the Fourth of July off, but even though my clinic was closed, there seemed to be a remote possibility that I would be deployed on a house call or video visit. That didn’t happen, but there was definitely some confusion there.

A few other things are happening to many doctors when they take time off. One is that we get messages from nursing staff or sometimes covering providers about patients that we know particularly well. That happens to me fairly often in my telemedicine Suboxone clinic for Bucksport patients. I have made it clear with them that I do not log into the EMR unless I get a text message saying there’s an issue for me to handle. That way I’m less tied down looking for interruptions in my vacation.

Another issue that sometimes cuts into our vacation time is refills of controlled substances. I see medical providers, colleagues, who would trust me with their patients or even their own lives either refuse to refill stable patients’ controlled substances or only do it for a limited number of days until I’m back at work. This either means I’ll be contacted on my vacation to refill the prescription they would not or I will have to do the math all over when I want to resume my patient’s usual intervals between refills. In that case the patient may have to pay a full copay for a 3-7 day prescription and another one when I refill their usual amount.

I was around when pagers were the most high tech handhelds (and cell phones back then were all over-the-shoulder). It was easy to be unreachable then. Instant connectivity can be great for those who need us, but how much of that is too much for us? The higher the constant availability pressure is during our normal work weeks, the more sense it makes to disconnect when you’re on vacation. Maybe if you’re the only one in your specialty in your county or state, you can’t disconnect completely, but in primary care, there are options – we are probably not quite as indispensable as we think we are…

And, as an aside, I have gone from one extreme to the other, then back again a few times in my publishing endeavors, sometimes posting twice a day and sometimes not for weeks. So, yes I’ve been a little quiet lately, but that is what happens when you pay attention to friends, family and other parts of your life besides “performing”. I’ll never stop, I’ve just been busy with some of those other things.

Why is it that every visit note has to rehash past medical and surgical history, active problems, allergies and sometimes even long narratives about the initial presentation of the problem at hand and long lists of prior testing?

In the electronic health record, when we start a new encounter, those things are usually right there in a scrollable sidebar. And when we print or fax completed office notes from the EMR, most systems could automatically include all those lists, if only as attachments.

Imagine the possible time savings and mental health benefits (less burnout) if, during visits, doctors wouldn’t need to click “import to note” a kazillion times, indication we had rigorously reviewed everything in the sidebar (because how much does anyone really think we can do in the few minutes available in each encounter for review of past medical, surgical, social history and so on?)

And during return visits, or just scanning old notes, we could quickly and easily catch up on the progress of the patient’s case if all the fluff didn’t gum up the chart note. Because in most notes in most cases, those things are fluff. If a diabetic has started on a new medication and they come back to review their blood sugar log, which is improved, and they report no side effects, those things we pretend to review in detail really are fluff. Of course we need to cover them in more detail with annual visits or with brand new problems, but most of what we do is following up on specific issues in the care of specific diseases.

Let us get right down to the purpose of the visit instead of trying to, or pretending to, do everything for everyone every single time they come in.

Vitamin D is back in the news. It has been one of my pet peeves over the years. We know what the average levels are, but we still don’t know if low or high levels mean anything for people without osteoporosis. Most insurance companies don’t pay for screening and now the Endocrine Society has officially advised against screening people under 75 without osteoporosis for vitamin D deficiency.

Think about it, the average BMI in this country is around 30, which is our definition of obesity. So it is the statistical average, which in most instances is how we define “normal”, but is it “normal” or “desirable” to be obese?

This piece is on my Substack today, paired with an essay on the same topic by Lilian White, MD who is in her first year of practice. We have a little series going called early and late career collaboration.

http://ACDW.Substack.com

On our way home from Friday’s housecalls I had to swerve for two dead ravens in the road. I don’t usually joke about death, dying or dead bodies, but suddenly found myself blurting out “two birds with one stone”. My assistant, who was a firefighter before entering the medical field, broke out in near-hysterical laughter.

“Gallows humor”, I said calmly.

“Exactly the word I was about to say”, she responded. “You don’t hear that word very often.”

Originally, the expression referred to when those convicted to public hanging at the gallows tried to be funny to relieve their own fear of dying. But now any joke about life or death situations can be called gallows humor.

We spent the last mile or two of our trip talking about how medical people and emergency workers seem to be able, or even have some sort of need, to make fun of situations that don’t seem funny to lay people.

In some ways, finding something comical in situations that involve death or disaster is a way of distancing ourselves from the tragedy of what we are witnessing. And at the same time, sharing a joke about it is a way for us to bond with other people who also must deal with tragedy on a regular basis in their work.

Of course, any public sharing of these macabre coping mechanisms of us life-or-death workers would be offensive or hurtful in most situations. But privately, between colleagues, I think it can be valuable in helping us carry on, no matter what.

As physicians or any other worker in this field of helping the sick and tending to the dying, we must live up to the expectations our patients have of our demeanor. Just like clergy, we have roles to play in people’s lives that are incompatible with lightheartedness or flippancy. This goes back thousands of years, to Hippocrates and beyond. Gallows humor is our secret little safety valve when the pressure of living up to these ancient standards threatens to be too high.