Thursday, May 28, 2009

Wednesday, May 20, 2009

T - 6 Weeks and Counting

I am back from vacation. It was a lot of fun and SO great to be away from work. Once I get my pictures together I'll try to post a few. I came back to piles of work, as usual. But, I had an amazing revalation when I looked at my calendar this morning and realized that there is less than 6 weeks until July 1 and the end of this year!!! I read a collection of short stories awhile back that traced an internist's journey through residency. One of them was about checking boxes and counting down. She reflected on how her life had basically become a tasklist and a countdown: how many more things to check off before I can go home, how many more days on this service, how many more nights on call, how many more months until residency ends, and so on. How right she is.

Saturday, May 9, 2009

The Medical Home

I've been hearing a lot about the "medical home" model lately and I honestly have not been very clear on what it exactly is. It seems to have started to get more press about the time I hit my "senior slump" and stopped doing medical student rotations with much content other than leaving by noon. This video provides a good, short introduction to the concept, and Wikipedia also has a basic article.

Overall, it seems like the model has some potential to make the primary care experience better for patients and physicians alike. It was interesting to learn that the model seems to have originated out of pediatric practices caring for children with chronic illness. The experience I had in medical school that came the closest to the "medical home" model was the month I spent on outpatient pediatric heme-onc. Multiple people saw the patient and his/her at the visit: physician, infusion nurse, and social worker were key. Then others like physical therapists, speech therapists, nutritionists, other specialists were added based on the child's needs. Translators were always available, usually in person. They seemed to do such a good job of addressing everything that some parents said they felt no need to see the general pediatrician for routine visits.

So I wonder if this model could be a good way to go in the future. I have no doubt that the electronic medical record (EMR) can help dramatically in coordinating care. Having spent a good chunk of time this year at a hospital where most clinics still did paper charting, I came to see how frustrating it could be to have no way of finding out anything about a patient in a timely manner. I do not think that EMR is a magic bullet that will save the system; there are many problems with cost, implementation, and coordinating EMR across different health systems that will need to be addressed over time. But it does seem helpful at providing an accessible record for all that care for a patient within one system.

Bringing in nutritionists, PTs, psychologists might be a way to help chronically-ill patients make lifestyle changes, and could help to ease the burden on primary care physicians who do not have enough time to address these issues at routine visits. Group visits and classes could also help to shift to a more preventive focus. Kaiser offers a lot of classes for patients with chronic illness, who are going to undergo routine surgeries, for child-birth and parenting, and even preventive health classes for the "average" person. Feedback I've heard from people have attended these has been mixed, but overall positive. Of course, there is instructor variability to take into account. But Kaiser does seem to have made progress overall in reducing death from heart disease (it's in all of their ads, but if you want to know more, start on p. 20).

I'm not really sure what the medical home would mean for specialists. Would it make referrals easier? What about for hospital-based physicians? Could it improve care after discharge, which is said to often be a critical time for patients? For those of us in diagnostic specialties it seems it could help with coordinating procedures and getting results to patients in a timely manner. How helpful it is it turn around a biopsy rapidly if the patient, who is anxious and stressed that he/she may have cancer, cannot access anyone to give him/her the results?

I am sure we will hear more about the medical home in the coming months as health care reform takes center stage in Washington. It is clear that we need some drastic changes in our delivery of care in this country. Is this one of the answers? I'd be curious to hear your thoughts.

Thursday, May 7, 2009

Home Call, Take 2

So I tempted fate blogging about home call while I was on call. It has been a really busy week. We've just been swamped. And I am really ready for a day off after working for days and days in a row. Luckily, I get my last week of vacation next week. I am SO excited.

Anyway, back to home call. Basically, you're sitting around waiting for the pager to go off. Depending on how heavy your home call tends to be, it can be a quiet night at home answering a couple of random pages here and there, or a total nightmare where you are basically working non-stop from home or going back into the hospital. When you have the heavy nights where you are up all night, there is no "post-call" day to recover. You go into work and work another full day. And if your program does long blocks of home call, you might be on call again that night and the next and the next.

Another thing I have discovered about call from home is that it makes it harder to get things done. There's something about paging someone back to a number outside of the hospital that seems to make it take longer for your pages to get answered, if they ever are. Computer access can be a nightmare depending on your hospital's system. You have no back-up nearby. If you do not know what to do, or just want to run a plan by someone, you have to call someone else, most likely your attendings. At 3 am you may not want to call them because as much as they say they are there anytime, they will not be happy to hear from you then.

Sunday, May 3, 2009

Call From Home

Since I am on call right now, I thought this might be a good time to discuss taking call from home. On one hand, I am really not complaining that I picked a field where I do not have to do q4 overnight call in the hospital. I am thankful for that on a daily basis when I interact with exhausted interns and residents.

But on the other hand, call from home is really not what it is cracked up to be. It sounds benign enough--you sit at home and get to answer calls from the comfort of your couch. If something is urgent, you go in. Or at some programs being on call "from home" also has some set time that you spend in the hospital each day. So you might work basically a full day and then go home and take call. However, you were technically on call "from home" all day, so none of the work you do counts towards duty hours. Pretty sneaky, huh?

Being on call from home has its drawbacks. You are basically stuck at home because you cannot go too far away in case you have to go to the hospital. Access to a phone and computer are needed at all times, so that eliminates things like going out to dinner. I guess if you had an I-Phone you could pull it off, but then you have HIPAA to think about when discussing cases in public. So you sit at home and wait for the pager to go off. And there goes my pager. How ironic. More on this later.