PRACTICE DIARY

Chapter 53

 

Fam Pract Manag. 2004 Mar;11(3):85.

One thing leads to another...

Gordon, an 82-year-old patient, had just gone into the hospital with his fourth gastrointestinal bleed in as many years. After his first, I had him scoped by Dan, our visiting gastroenterologist. A cecal arterial-vascular malformation and scattered sigmoid diverticula were all Dan found, but since Gordon had stopped bleeding by the time of his scoping, Dan wasn’t sure where the bleed was coming from – not that it mattered to Gordon. After an endoscopy, colonoscopy and four units of blood, he was content to end the work-up, go home and hope it never happened again.

Unfortunately, over the next several years it happened several more times. Each time, like clockwork, Gordon stayed at home for three days, came in with a hematocrit of 19 or 20 percent, stopped bleeding by the time he hit the hospital, and went home a day or two later after a three-or four-unit fill-up. The last bleed, however, dovetailed with one of Dan’s visits, so he thought to rescope Gordon; it had, after all, been almost four years. “It’s definitely diverticula bleeding,” Dan called to tell me.

“He needs a hemicolectomy. Do you want me to get a surgeon involved?” “No,” I said diplomatically, “let me talk with him first about his options. Maybe he’d rather just come in for periodic transfusions.”

Gordon opted for the surgery, having grown tired of his unpredictable routine. Ken, a surgical colleague, agreed to do it but sent him for a carotid Doppler study first, having heard a bruit on Gordon’s preoperative physical that had him concerned. The report justified Ken’s fears: 20 percent flow on the right and a trickle on the left. “Looks like Gordon needs an endarterectomy before I can do his resection,” Ken advised.

Loie, a vascular surgeon in a nearby city, graciously saw Gordon on short notice. On her preoperative exam, she thought the bruit was really a murmur, so she sent him for an echocardiogram. Several days later, I got a call from Gregg, one of her cardiology colleagues. “The echo showed critical aortic stenosis,” Gregg said, “but we decided not to do anything about it because Gordon is, amazingly, asymptomatic.” (He could split a half-cord of wood on a good day.) The cardiologist did, however, do a catheterization and put in a stent, as Gordon had an 80 percent occlusion of his right coronary artery. “He should do well,” he said.

“I hope so,” I told him. Then, thinking of how Gregg had fixed his heart so that Loie could fix his neck so that Ken could fix his belly, I said “Getting old is definitely not for sissies.”

Locum tenens II

My family physician buddy Jeff has been enjoying his new prac­tice arrangement as a locum tenens. A true nomad, he likes traveling from place to place and calling his RV home. So far, he has been as far east from California as Nebraska and as far north as Washington. He seldom knows where he’s going to be more than a month or two ahead of time, but he never wants for job offers; locum tenens companies e-mail him almost daily with propositions. No physician surplus here.

He’s generally paid $50 per hour. This may seem low, but the upside is that he has no overhead and doesn’t have to carry a beeper. Although he works five days a week, eight hours a day, he gets to take as much time between jobs as he likes. His wife, a nurse, travels with him and has been able to find work as well, when she’s not caring for their four trailer cats.

Jeff was in town for a few days between gigs, so we met for a bike ride and lunch. I couldn’t resist scheming: “You know, Jeff, since it appears that you’re going to make a career out of this, maybe you could help other docs who are considering doing locum work. You could advise them about contract negotiations, how to get higher hourly rates or other aspects of being a peripatetic physician. You could start an academy – no, that’s too formal – an association of locum tenens physicians: ALTP. Hold that acronym. What about ALP? You could be the Association of Locum Physicians. Much better. You can represent the physician workers and keep us from being exploited by the locum administrators. Hey, pretty soon you’ll be an administrator yourself!”

“Great. Then will you come and work for me?” Jeff asked, facetiously.

“Afraid not,” I said. “I’m a home boy. Thanks for the offer, though.”

Dr. Brown, a solo family physician living in Mendocino, Calif, is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.


 

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