#pgy-4: i'm out of ideas

[pleasedotheneedful]

Sharing a story I posted to a fb group for docs with ADHD last week:

Story time. I was in our peds urgent care on Thursday and my first patient was a 7 yo with behavioral concerns who was recently expelled from school. Teachers says he won't pay attention, is aggressive, acts out. Mom says she does struggle with the attention and acting out at home. While I'm in the room the kid is pretty standoffish but I try to make sure I talk to him while also addressing mom. He's playing with some toys a little loud but otherwise he's pretty appropriate in the room. Mom brought him mostly to drop off the school evaluation that was done, which flagged for ADHD. I go to staff with my attending and we each end up discovering the other person has ADHD. It's urgent care and he has an active PCP so we're not starting meds but my attending is addressing all of an overwhelmed mom's concerns about the behaviors and the possibility that this is ADHD. While she's doing that, the kid looks at me and goes "do you have ADHD?" Of course I said "I do, actually!" And after that he opened up, he asked me to play with him which I absolutely did. Maybe it changed his perception that this was some strange condition and saw this doctor who had it, and felt okay about it. To think, there's another peds attending here who is convinced I'm "probably a better internist than a pediatrician" because I'm not good at playing "guess the esoteric thing I'm thinking of." And my program just seems to follow his lead (even though he is notoriously harder on med/peds residents). This was another reminder than I picked med/peds for a reason, despite the best efforts of some bad actors.

#peds side of the moon #pgy-4: i'm out of ideas

[pleasedotheneedful]

me: *in the peds ED, admitting a psych patient to medicine for obs*

hospitalist: ok but why do they need admission to us?

me: well, they're still having SI and--

hospitalist: I mean, that sounds like the exact thing for the psych unit

me: yeah, I know. but they still wanted them to come to medicine for obs until tomorrow morning. maybe with a repeat tylenol level

hospitalist: ... *sighs* ... I'm not mad at you guys, I know you did your due diligence

me: hey man, I do a lot of adult hospitalist--

hospitalist: oh, so you know

me: oh absolutely. I fight that fight all the time.

hospitalist: alright yeah that's fine, we'll take them. I'm probably not getting that tylenol level though

#peds side of the moon #pgy-4: i'm out of ideas #the verbal head nod

[pleasedotheneedful]

Re: that horrible incident from peds urgent care last fall

My PD attempted to put me on a "remediation plan" so I called GME who said "uh no all remediation plans must come through us first". The plan involved 30-something extra peds urgent care shifts, at the expense of my evenings, elective, and educational time. A plan made for someone to fail.

I also called a med ed-savvy lawyer who helped me write a rebuttal letter. The CCC met with me a month later, reduced the number of shifts by about 66%, and then said "no, this is a 'performance improvement plan.'" They did not have me sign any weird documents.

In the same meeting they also said this wasn't based on one attending's feedback, but at no point do they ever show additional negative feedback and nor have I come across any in the extra shifts I've done. In fact, one told me I didn't need to be so overly cautious because I knew what I was doing.

I was going to provide another rebuttal but decided you know what, fine, I can handle the modified extra shifts. I didn't want to burn bridges, I'm still grateful I was able to come here.

However, I worked with the dreaded attending today and it was as bad as one can expect--as a PGY4 I was grilled like an intern playing "guess what I'm thinking." Later they asked me what my plans were after residency, I mentioned a couple of job offers I was weighing and they said something to the effect of "you're probably a better internist than a pediatrician."

Honestly, I'm not even mad at him. This is who is is, this is what he does. And I still respect the way he thinks about patients, and he's pretty knowledgeable--most attendings couldn't keep up with him.

I am pissed at my program because they have not only NOT supported me during all this, but took his feedback as gospel and put me through all this bullshit... then continued pulling the scab with a new meeting every 3-4 weeks. I process, I get better, and then we start all over again.

This is becoming physically intolerable to deal with over and over again based on something that remains largely unsubstantiated. I really don't want to get my attorney back in the fold but if the program tries to add more bullshit to this "improvement plan" we're going full-court press.

Also, huge conflict of interest as the attending in question is also head of GME.

#peds side of the moon #pgy-4: i'm out of ideas

[pleasedotheneedful]

I had a family in clinic who previously decided to stop their kid's polio vaccine series because this was "a disease of another country" or something, followed by some fairly ignorant statements about how refugees should stay where they are

However, the evolution of the Ukraine crisis convinced them to finish the kid's polio series so I was like uuuuuuhhhh ok 👍

#peds side of the moon #pgy-4: i'm out of ideas

[pleasedotheneedful]

The entire peds clinic was kind of a shitshow on Friday. Multiple attendings out sick.

Enough residents present but the bottleneck was pretty obvious, and we had families up and leave after triage because of the wait times. They actually had to pull attendings from inpatient services, but obviously they couldn't go the whole afternoon that way.

The reason I'm posting this is to highlight two things: First, most hospital systems are designed to run with minimal backup. There isn't a contingency past the first level. Second, they clearly need more staff in outpatient pediatrics. Based on the national recruiting ads I'm seeing, I suspect this is a nationwide need but certainly we're no exception.

Despite everything that's happened, I'd love to come back and do at least PRN at my hospital. They just have to decide whether they're willing to take the small effort to say yes. Co-residents have told me it would be a great idea/they'd love to work with me as an attending.

so idk lol hopefully this isn't another situation of them just waiting for the problem to go away, although that is pretty standard op

#pgy-4: i'm out of ideas

[pleasedotheneedful]

"The patient in room 35 told me there's like, nothing there. Completely blind [at baseline].

Which is interesting because he went on to tell me about how he plays baseball in a rec league."

#pgy-4: i'm out of ideas #screaming internally #how does he keep his eye on the ball

[pleasedotheneedful]

We had a crazy snowstorm on Monday and the clinic was still open. I took one look at the roads and decided all my in-person visits would be converted to telemed, which our front desk was able to do for me.

I posted about it in a physician group on facebook.

Most people were supportive and said it was a good call for me and my patients. But someone chimed in that I can't make that decision and I have to call my program director to make sure it's okay, and reiterated this after I said there wasn't time for that because people were already trying to drive in (the alternative would be to cancel my visits or hand them off to the one resident that was able to get there). She was very insistent, and then went on to say "well I know you struggle with executive dysfunction" (my ADHD is not a kept secret). Still not sure what that has to do with any of this, though...

After a brief back-and-forth I decided to just let it hang like the onion fart that it was, and by the time the day was over moderators had reached out to let me know she was being a shithead and had removed her comments. It wouldn't have been such a big deal but this group was specifically geared at people who are burned out, and often this is from administrative bullshit so it was uniquely offensive.

Ironically, I later remembered I had run the idea by my chief in the morning but honestly that's beside the point.

#pgy-4: i'm out of ideas #screaming internally

[pleasedotheneedful]

We got an e-mail about changing standard orders to alleviate the burden on our RTs.

Which is fine, but when is the hospital going to address the long-standing (seriously, pre-pandemic) shortage of RTs?

I also got an e-mail about missing my last two workplace BLS recertifications (because I was pulled to cover or the service was insanely busy). I am ACLS and PALS certified, why was my BLS testing not included with this? Why am I not grandfathered in?

#pgy-4: i'm out of ideas #pgy-4: one foot out the door

[pleasedotheneedful]

"You can call my primary doctor, he'll clear all this up. He's my personal doctor, he's a good friend of mine."

I've known this guy since I was an intern. Very self-sufficient with some chronic medical issues. Works as a freelance trucker, switched contracts and the new company has an outside corporation handling their occupational health. The new occ health folks decided he needs a new set of CDL clearance forms despite his previous ones being up to date, and a sleep study.

The funny thing is, even though they think he needs the sleep study they insist that I order it. This guy meets physical criteria for OSA screening but has never, ever had a symptom related to it. So like... you're a doctor too, right? If you think he has sleep apnea, why don't you order the study?

I was immediately suspicious when I found out who the occ health company was--let's just say they also own a nationwide chain of urgent cares.

Anyway, what he said was correct: for this guy, I will handle his forms and order the sleep study, with an extra page in the return fax expressing my concerns about how they handled this.

#pgy-4: i'm out of ideas #screaming internally

[pleasedotheneedful]

Job hunting continues.

I'm not sure why I'm so hellbent on being part of a giant hospital corporation, whether that's the maelstrom with the five-star hotel attached to it or the county hospital system where I'm finishing up residency.

I interviewed for a job with the former after getting a sound reference from someone who had been my senior resident, and despite being told I nailed the interview day they suddenly decided not to move forward. It caught me off-guard and I was kind of upset as I got zero feedback when I went to find out what happened. Only a month later did I stop and consider that I might've mentioned said maelstrom in a podcast about overpaid C-suite hospital execs; it was an exciting part of my CV so everyone asked about it.

Now it seems like I'm begging my current program/hospital for the job I want. Maybe I do know why I'm hellbent on it... it's the system I was brought up in, it's familiar and I'm avoiding change. I do like it here, I have some awesome mentors, and I enjoy the relationships I've developed but I shouldn't be pleading for a position when other places are itching to hire me and willing to compromise so I can find the spectrum of practice I'm looking for.

With my wife having signed a lucrative attending contract, it's even less about money for me (thankfully she has been very supportive with all this). And going beyond that, it should be about working in an environment where I'll thrive. Where I can maintain my advocacy work (for patients AND staff) without worrying about corporate appeasement or being stalled by a wall of bureaucratic bullshit (and I cannot tell you how many times I've had an idea that hit that wall).

Although I have plenty of flaws, at the end of the day people here know I go the extra mile for my patients and for my colleagues when it matters the most--and my patients certainly know it too. People have been asking me if I'm planning on staying. If that isn't enough to try to retain me and create the job I'm looking for then I need to head somewhere that's ready for me.

I keep forgetting that this is one of the reasons I got into medicine: you can choose your own adventure.

#pgy-4: i'm out of ideas

[pleasedotheneedful]

I'm getting a how-not-to crash course in managing academic inpatient teams this week.

Let me preface this by saying everyone is super nice.

But the workflow is totally fucked.

Teaching is important, and keeping tabs on people is important. But there's a certain point where you're doing too much of it and break the efficiency of your unit. If your senior AND interns are staying hours past their shift end for multiple days something isn't right, and it isn't them. I feel like I don't even have time to run the list with my interns (because I'm running around trying to put out fires by myself), and thus I don't even know how I can help them out.

I mean, look, when you're out in practice you do things how you prefer. But when you're leading a team you have to consider a lot more than the clinical part. It's only September, interns need time to learn the process and seniors need time to help them. If you don't, you'll find that discharges are delayed, consults are late, and patient care is hindered despite any effort you're pouring into clinical decision-making.

My request to delay teaching this afternoon was effectively denied, and when the attending asked how they could help we had no idea because no one had enough time to review all their tasks. I need to help the interns prioritize but I can't do that when I'm running around putting out fires by myself. I ended up signing out to the night senior directly... I was short call.

I am going to ask that we table round and stick to new/sick/interesting patients as a team tomorrow, as I'd suggested at the beginning of the week when I was asked. Not sure how that'll turn out but I'm down an intern tomorrow so something has to give.

Later on I'll actually write a cohesive post about how I think teams are supposed to run when I get my brain cells back

#screaming internally #pgy-4: i'm out of ideas

[pleasedotheneedful]

Omg seeing how you fight for your patients makes so happy and I wish I could see a doctor like you. I hate going to the doctor because when I was 14 the pediatrician I saw for my physical called me fat(I was 5’2 and weighed around 115lbs so while I wasn’t super skinny I was by no means fat) and then when I was 20 this one doctor kept calling me a “healthy young girl”(First I’m a full grown woman second I had the flu and was tachycardic being rehydrated via IV) but I swear if I came across a doctor like you I might want to actually see a doctor. You sound like you actually listen to your patients and take their concerns seriously

Thank you for this, seriously. I often run long and rely on no-shows (and now phone visits that I may end up calling after hours) to stay on schedule, but you can only do so much in a typical 15-30 minute visit. There's something to be said for efficiency but that has a ceiling; sometimes you realize the best thing you can do for that patient is slow down and just listen.

The most rewarding thing I've gotten out of all of this are that these same patients continue to request me as their new PCP despite knowing I only have another year before I graduate. Even the patient that blew up on me--I know I took a risk being openly blunt in response but she appreciated it.

I do recognize I have to set boundaries and can't go balls-out for every single patient care issue, but these have been pretty basic issues that were needlessly complicated by a broken system.

I'm sorry you had those experiences in your past visits and I know they're all too common. FWIW we use percentiles in pediatrics when making diagnostic calls on weight, but I ran the numbers relative to your age and you were nowhere near those percentiles. Either way though, there's a tactful way to bring that up. I've had body image issues since adolescence, obviously it's a pretty sensitive topic and particularly so in kids.

Thanks again for sending this! I was having a bit of a week and this super lifted me up.

#pgy-4: i'm out of ideas

[pleasedotheneedful]

If you ever feel dumb, know that I failed to find a previously documented sacral dimple on an infant because I didn't look far enough into the gluteal cleft.

I'm a PGY-4 lol

#peds side of the moon #pgy-4: i'm out of ideas

[pleasedotheneedful]

yesterday was a NICE day in clinic

a patient I was reluctant to pick up on my panel (a situation I complained about on tumblr as my attending basically hoisted her on me as a patient we poached from FM) took some basic measures and dropped her A1c from 11% to 7% in the course of about 6-7 months. like all she did was cut way down on the regular soda/sweets. she looks better and is mentating much better than when I saw her initially. super motivated, I'm not sure what I did differently though. but I gave said attending the opportunity to gloat in her head when I let her know how this turned out.

I had a random add-on phone visit yesterday for a guy who is on chronic opiates. is currently being bridged to pain management but the earliest visit they gave is like a month from now. saw his PCP a month ago who continued it but only wrote for two weeks worth (there are pretty tight limits on length of opiate prescriptions here). it would have been easy to say "well I can't really write opiates for someone I've never seen" but he's established in our system and I think his PCP was on vacation or something. next visit with that PCP was also in a month. so I made up a pain plan with the patient on the fly where I'll be refilling his opiates contingent on him checking in with me once a week, until he sees his PCP/pain management.

patients I see as add-on urgent visits continue to request me as their PCP, even under the caveat that I'm graduating next year. can't peg down exactly what it is but I think I'm doing something right. and the entire day ran seamlessly.

also, not sponsored but doximity faxing has made my clinic life SO MUCH EASIER.

#screaming internally #pgy-4: i'm out of ideas

[pleasedotheneedful]

I had a patient for hospital follow-up where I clearly had missed the point. I read the discharge summary and went down the rabbit hole of a high renin and severe hypokalemia. All the while slipping past the part where there were two weeks of preceding nausea/vomiting that needed an etiology.

Next thing you know, I'm looking up stuff in front of them and so is my attending. The intern who did the discharge was also around. My attending was the one who eventually was like wait... what the hell are you talking about she was vomiting a lot, of course she was hypokalemic with weird renin. I'm not sure why the extra work-up was initiated, either.

I think everyone had brain fog this afternoon, I know I did.

Anyway, despite all of that, the patient still insisted I become their PCP (even after I said I was graduating in six months). I guess it was the willingness to check into things and be transparent?

#pgy-4: i'm out of ideas #screaming internally

[pleasedotheneedful]

in this edition of "who does the paperwork" I tried to give PM&R a heads up on a patient I was sending their way for a complete functional assessment (with the paperwork attached) and the doc was like "I don't do disability evals or complete paperwork. please update your patient TY"

the patient is being eval'd for disability for the first time. I know the questions those forms ask. I need PM&R's detailed assessment, and we've sent patients to them for this exact thing before. This was just the first time I gave them a heads up.

I asked one of my attendings and they were like "well, if their limitations are pretty obvious (in quadriplegia for example) then I fill it out. otherwise if they need a functional assessment PM&R does it, and this is something I discussed with one of their faculty a few years ago who agreed."

I think I was just irked at the rehab doc coming back aggressively. I explained this to him in a reply and said if they still felt uncomfortable doing the assessment and/or paperwork, to let me know and "I'd reschedule them or figure out an alternative with my faculty."

I'm really working on my interdepartmental counter-aggression. four years ago I probably would've come back hot. I'm getting results pushing for patients like this but I'm trying not to mash on anyone's toes.

#pgy-4: i'm out of ideas #screaming internally