Aug 2008
A Typical Work Day
On a
typical work day, I head out the door between 7:30 and 8 am. After
arriving at the hospital I usually start my inpatient rounds in the
ICU. The physician’s assistant or nurse practitioner who helps us
in the hospital will see some of the patients first, but I’ll just
pick up a chart of someone on the list and dive in. I’m pretty fast
making rounds now because I’ve learned the routine at each
hospital: where to find the charts, and where to find the
information in
the charts. I’ll start to fill in
some of the relevant information for my chart note. Every patient
gets a “progress note” (even if there’s not much progress) which
contains certain information meant to enhance inter-provider
communication, supply advice between consultants and attendings,
and provide a medical-legal record. A progress note on an
established patient consists of a heading with the date and the
identity of the particular note-writer e.g. “Cardiology”, and then
several categories of content: Subjective (the patient’s symptoms),
Objective (blood pressure, pulse, examination findings, lab
results, test results), and then Impression and Plan-or for
consultants “Recommendations.”
So I’ll fill in some of the note with data from reports on the chart, and then go see the patient. Sometimes the visit is brief (patient comatose, or demented, or feeling well) and sometimes it takes a while (new patients, family present with lots of questions, etc.). Then I’ll fill in the exam findings and formulate a plan. [I’ll try to attach a typical note below for illustration.] Somewhat archaically these notes are hand written. That’s a subject for a separate post, but for now let’s just say that some doctors really do have the proverbial terrible handwriting that makes their notes in the chart next to useless.
At some point, usually before rounds are completed, the office calls saying that I have patients waiting. I’ll go and see anywhere from three to 12 patients in a row before taking a break, usually to go back to the hospital to see more patients or interpret some “studies”. These are diagnostic cardiac tests. While I’m in the office, I will interpret studies such as echocardiograms, nuclear stress tests, EKGs, 24 hour rhythm monitors, carotid artery ultrasounds, or computed tomographic angiograms (CTAs) in between seeing patients. There are often phone calls, too, from ER physicians wanting to admit or transfer a patient or from other physicians with questions or concerns.
At lunchtime I usually go back to the hospital to see more patients on rounds or interpret similar diagnostic studies which have been generated at the hospital. Often there will be more involved diagnostic procedures to be performed at the hospital such as coronary angiograms. Sometimes there will be a pacemaker to insert. Each of these activities is accompanied by its own arcane set of paperwork to be completed and placed in the chart. I probably sign my name and attach the date about 50 to 100 times a day between office and hospital.
Finally, by the end of the day the last patient has been seen in the office and hospital, the last chart signed, the last EKG read, and it’s time to go home. Usually I try to leave by 6:15 pm or so. By staying efficient and keeping up during the day, this goal is usually accomplished.
I typically will see 15 to 25 office patients and 8 to 15 hospital patients a day. I will probably read 5 to 10 CTAs, 10 to 15 echocardiograms, 50 EKGs, 5 to 10 rhythm monitors, and perform 2 or three arteriograms.
This is my typical day’s work. Some days are busier, some a little slower. Some are downright crazy usually due to emergencies or a sudden deluge of new consultation requests, often in the context of one of my colleagues being away on vacation. I’ve managed to adjust my work style to get it all done, but at some cost to patient relationships. All in all, my days are usually full and rarely boring. There are some routine elements to the work with infinite variations. More on those in a later post.
So I’ll fill in some of the note with data from reports on the chart, and then go see the patient. Sometimes the visit is brief (patient comatose, or demented, or feeling well) and sometimes it takes a while (new patients, family present with lots of questions, etc.). Then I’ll fill in the exam findings and formulate a plan. [I’ll try to attach a typical note below for illustration.] Somewhat archaically these notes are hand written. That’s a subject for a separate post, but for now let’s just say that some doctors really do have the proverbial terrible handwriting that makes their notes in the chart next to useless.
At some point, usually before rounds are completed, the office calls saying that I have patients waiting. I’ll go and see anywhere from three to 12 patients in a row before taking a break, usually to go back to the hospital to see more patients or interpret some “studies”. These are diagnostic cardiac tests. While I’m in the office, I will interpret studies such as echocardiograms, nuclear stress tests, EKGs, 24 hour rhythm monitors, carotid artery ultrasounds, or computed tomographic angiograms (CTAs) in between seeing patients. There are often phone calls, too, from ER physicians wanting to admit or transfer a patient or from other physicians with questions or concerns.
At lunchtime I usually go back to the hospital to see more patients on rounds or interpret similar diagnostic studies which have been generated at the hospital. Often there will be more involved diagnostic procedures to be performed at the hospital such as coronary angiograms. Sometimes there will be a pacemaker to insert. Each of these activities is accompanied by its own arcane set of paperwork to be completed and placed in the chart. I probably sign my name and attach the date about 50 to 100 times a day between office and hospital.
Finally, by the end of the day the last patient has been seen in the office and hospital, the last chart signed, the last EKG read, and it’s time to go home. Usually I try to leave by 6:15 pm or so. By staying efficient and keeping up during the day, this goal is usually accomplished.
I typically will see 15 to 25 office patients and 8 to 15 hospital patients a day. I will probably read 5 to 10 CTAs, 10 to 15 echocardiograms, 50 EKGs, 5 to 10 rhythm monitors, and perform 2 or three arteriograms.
This is my typical day’s work. Some days are busier, some a little slower. Some are downright crazy usually due to emergencies or a sudden deluge of new consultation requests, often in the context of one of my colleagues being away on vacation. I’ve managed to adjust my work style to get it all done, but at some cost to patient relationships. All in all, my days are usually full and rarely boring. There are some routine elements to the work with infinite variations. More on those in a later post.
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Commuting Redux
Well I tried it again. This time I
located a shower I could use in my office building, so when I got
to work I showered off which felt much better. Unfortunately
somewhere along the way to work I lost my air pump which must have
worked itself loose and fallen off. There were no major car-cyclist
mishaps but the traffic was heavy. Anyway I still feel good about
getting some exercise while traveling back and forth to work.
Here’s my route, about six miles one way:
Quantity vs. Quality
Which is the greater good: to serve
more people or to serve fewer ones better? To be more specific, in
my current medical practice, I see a far greater number of patients
than I did previously. Consequently, in a given day, I spend less
time with each patient. I now can pretty much classify any new
patient and their symptoms into one of a relatively small number of
categories within the few couple of minutes of the encounter.
Rapidly I can begin to triage their workup and select what
diagnostic or therapeutic options I will employ. There is a limited
number of clarifying questions I will ask. I try to do a little
patient education regarding new drugs or unfamiliar diagnostic
tests. If the patient has any questions I try to answer them. Then
I speak some “transitioning” language so as to prepare the patient
to be checked out by my staff. And I move on . . .
Many of our patients are poor or indigent. Many don’t have a lot of formal education. There’s a high incidence of smoking, obesity, diabetes, and sedentary lifestyles. It’s difficult to explain complex concepts of cardiac anatomy and disease pathophysiology to them. Usually if I try to engage them in the decision making process they just shrug and say “whatever you think, doc”. The most worrisome disorder - coronary artery disease - is highly prevalent and dangerous when undiagnosed. Yet the symptoms are often misleading or non-specific. The physical exam is nearly useless. But with a ten second CT scan that I might order, I can instantly see a “snapshot” of their cardiac risk that creates immediate direction for their therapy-or major reassurance when negative.
So what’s better? Should I spend more time establishing a relationship with these patients (most of whom, if new patients to the practice,are referred anyway by the primary providers for a consultation) or should I attempt to see a larger number so as to provide more of them with useful even potentially life-saving information and advice? I wonder . . .
Many of our patients are poor or indigent. Many don’t have a lot of formal education. There’s a high incidence of smoking, obesity, diabetes, and sedentary lifestyles. It’s difficult to explain complex concepts of cardiac anatomy and disease pathophysiology to them. Usually if I try to engage them in the decision making process they just shrug and say “whatever you think, doc”. The most worrisome disorder - coronary artery disease - is highly prevalent and dangerous when undiagnosed. Yet the symptoms are often misleading or non-specific. The physical exam is nearly useless. But with a ten second CT scan that I might order, I can instantly see a “snapshot” of their cardiac risk that creates immediate direction for their therapy-or major reassurance when negative.
So what’s better? Should I spend more time establishing a relationship with these patients (most of whom, if new patients to the practice,are referred anyway by the primary providers for a consultation) or should I attempt to see a larger number so as to provide more of them with useful even potentially life-saving information and advice? I wonder . . .
Obsessions and Balance
Recently I’ve become interested in
learning a little about HTML and CSS. I started with a reasonable
desire: make a family web site. Its purpose: share thoughts, family
news, photographs, and links to other projects (my boat-building endeavor) and
hobbies (cycling). There was a web design program (iWeb) included
in the iLife suite packaged with every Mac. I played around with it
some but decided I wanted a little more flexibility. That led to a
lot of web research and eventually I selected RapidWeaver because it seemed to have a good
balance between ease of use and options in page layout. Or so I
thought.
I also picked up a well-written intro textbook on HTML and CSS (Head First HTML published by O’Reilly) which was a perfect level of simple and useful for a semi-intelligent newbie like myself. As I began actually constructing the content of the site, I became dissatisfied with the built in themes of Rapidweaver and so I looked for additional themes. I started with research into free themes available on the web and there are quite a few. People have done a lot of work to put these themes together and provide the code underlying them. I selected one but rapidly learned it also had some elements that were sub-optimal (primarily due to color conflicts between fonts and page backgrounds). So I tried to use my newly-found meager HTML skills to pick new colors. That lead to more conflicts, more research, more web time, more confusion, with a slow slide into frustration and a gradually increasing obsession to get the thing right. I solicited help from my computer-savvy brother-who tried to help-but eventually I realized the whole project was out of kilter.
That is, the effort involved had outstripped the original purpose: enhance the family life. Now my little obsession was becoming detrimental to the greater good. It was time to re-balance.
So I ditched the original theme because it was too much work (even if it was free) and paid $12 for a commercial theme I liked just as well and was better designed. And I told myself to relax and let it go. The darn thing can evolve over time--doesn’t have to be perfect the first week. So the lessons:
I also picked up a well-written intro textbook on HTML and CSS (Head First HTML published by O’Reilly) which was a perfect level of simple and useful for a semi-intelligent newbie like myself. As I began actually constructing the content of the site, I became dissatisfied with the built in themes of Rapidweaver and so I looked for additional themes. I started with research into free themes available on the web and there are quite a few. People have done a lot of work to put these themes together and provide the code underlying them. I selected one but rapidly learned it also had some elements that were sub-optimal (primarily due to color conflicts between fonts and page backgrounds). So I tried to use my newly-found meager HTML skills to pick new colors. That lead to more conflicts, more research, more web time, more confusion, with a slow slide into frustration and a gradually increasing obsession to get the thing right. I solicited help from my computer-savvy brother-who tried to help-but eventually I realized the whole project was out of kilter.
That is, the effort involved had outstripped the original purpose: enhance the family life. Now my little obsession was becoming detrimental to the greater good. It was time to re-balance.
So I ditched the original theme because it was too much work (even if it was free) and paid $12 for a commercial theme I liked just as well and was better designed. And I told myself to relax and let it go. The darn thing can evolve over time--doesn’t have to be perfect the first week. So the lessons:
- Free is great but sometimes means more work
- Projects must be re-assessed for harmony with their original purpose
- Don’t create pressure to finish something that’s really open-ended-or, in other words: enjoy the journey instead of anticipating the destination
Big problems with Obesity
There are a lot of complications that
result from obesity. Here are some that I observe on almost a daily
basis:
- Obese people can’t exercise easily, which only compounds the difficulty in losing weight, since most studies have shown that exercise is a requisite for permanent successful weight control.
- It may prevent needed diagnostic studies--there are weight limits for the tables used in medical imaging, for example. Even if one is under the weight limit, the bigger the patient the worse the quality of the study--fat scatters X-rays and exacerbates artifacts.
- High blood pressure is difficult or impossible to control
- Diabetes is difficult or impossible to control
- Cholesterol levels are difficult or impossible to control
- Obese patients wind up taking lots of medicines, sometimes ten or fifteen or even twenty different agents-expensive!
- It promotes blood clots in the legs and lungs--potentially fatal
- Obesity increases the risk of heart disease independently of other risk factors
- It increases the risk of arthritis and early joint replacement
- Chronic low back pain and accelerated arthritis can lead to painkiller addiction
The Long Ride
05 August 2008
Categories: Cycling
Categories: Cycling
I finally did it. For weeks I had been
meaning to get up some weekend morning and go for a longer ride on
my bike. But laziness intruded, other pleasures beckoned, and I
procrastinated. This past Saturday I made myself get up and get out
on the road before 7 am to beat the Tennessee heat. My plan was to
start slowly in pace and then build up. After an hour on a course
of gently rolling hills, my average was about 16.3 mph-faster than
I had intended. So I slowed down and took a break, stopping by a
babbling stream in the shade, where I got off the bike, stretched,
and re-hydrated. Then I got back on the bike and felt
much better. The remainder of the ride was
pleasant (after one short but gut-wrenching steep hill) and I
returned home a bout 9 am after 28+ miles. I savored my sense of
accomplishment. My ride didn’t interfere with the rest of the
family’s activities because save one they were all still asleep
when I returned. So the lesson (learned again and again): start
your day with something you want to accomplish, get it done, move
on with your day. The key is to start early. Getting the
lazy butt out of bed is the biggest hurdle, but it’s worth
it.
Odd & Beautiful
July 31
Some recent observations and sights while cyling:
* A flock of at least 25 turkey chicks scrambling behind Mom Turkey around a pond near Hendersonville
* A woman at 6 am walking one small dog and pushing a 1950s style baby carriage with her other small dog in the carriage!
* A beautiful sequence of irrigation sprinklers spewing misty spray by the side of the road
* A quick red brown fox carrying breakfast back to her kits in the den
* Large man in large truck pulls up next to me at a traffic light, leans out the window while we’re waiting and says “Yeah, you might as well bring your shavin’ kit to this light cuz’ it takes so long . . .”
Some recent observations and sights while cyling:
* A flock of at least 25 turkey chicks scrambling behind Mom Turkey around a pond near Hendersonville
* A woman at 6 am walking one small dog and pushing a 1950s style baby carriage with her other small dog in the carriage!
* A beautiful sequence of irrigation sprinklers spewing misty spray by the side of the road
* A quick red brown fox carrying breakfast back to her kits in the den
* Large man in large truck pulls up next to me at a traffic light, leans out the window while we’re waiting and says “Yeah, you might as well bring your shavin’ kit to this light cuz’ it takes so long . . .”