The chronicle of a lonely do-gooder family doctor who survived.

Wednesday, December 31, 2008

New Year's Eve, My Last Day in B-town

I have a family I have been taking care of since 2001. They are from Iraq and I have seen them through so much. They were basically brand new refugees that came through Jordan when I first started seeing them. There are six in the family, including a child who was a newborn in 2001. The mother had *severe* PTSD, to the point of mental status changes and total incapacity. I had never seen real, acute post traumatic stress outside of psych rotations in med school and it was scary seeing it on my own. At my current practice, DSHS wasn't able to provide an interpreter and, although the community mental health system exists as a theoretical safety net, in practice it was just impossible to get her in. Multiple times, through the father and son who spoke a little English, I told them outright that they needed to get into a community health clinic, that I didn't think I had the resources I needed to treat them. I even called and made appointments, printed out information on refugee support services, but they kept coming back to me. For some reason, wisely or unwisely, they decided I was their best chance at getting help.

So I basically shot from the hip and did what I thought was best, started SSRIs and alpha blockers, treated insomnia, saw them frequently for longer visits and talked to them about their experiences. Treated the childhood illnesses, diagnosed an appy, helped the dad through a herniated disk, got the mother some surgery to repair a chronic eardrum rupture.

Now, slowly, over eight years, everyone is doing great. PTSD is totally in control on sertraline. Two of the kids are over 18 and lost medicaid coverage and so I've just been treating them on the side whenever I could for minor things. The mother who spoke no English and had a GAF of 20 eight years ago, now speaks near perfect English and seems totally normal to anyone she meets.

Every time I see them, their eyes brighten, they grab my hand warmly, and they are so grateful. This was a family I was so sad about having to say goodbye to after leaving this practice.

Today, my last day seeing patients here, they just came in for a scheduled visit. They are going back to Iraq for a visit for the first time and needed prescriptions refilled and a travel medicine consult.

The first thing they said to me when I walked in the room was "We heard you are leaving. We're coming with you. Tell us where you'll be and how we can go there." It turns out the father works at a barber shop not far from the community health center I'll be working at and it's actually totally convenient for them. Because they are listed as Arabic speakers in the DSHS system they will automatically have an interpreter show up for their visits (not that they need it anymore). They will get to see the mental health workers at the clinic. They will get much needed dental care for the first time. *And* I will get to see the two uninsured kids.

After the visit, they congratulated me profusely on the coming birth of my son and insisted on taking pictures of me to take back to Iraq to show the family there.

Wow. I swear to god, this is why I got into medicine.

Tuesday, December 23, 2008

Busy busy

It's been more than a month since I blogged?!

Life has been pretty damn hectic since I dropped the bomb that I'm leaving my job. I mean, there was all the credentialing and paperwork for my new clinic at the 45th Street Clinic, but tying up loose ends at my current practice has been unreal. I started there eight years ago as just a temporary gig while Shiree finished her training (thinking we would probably end up moving where she could find a job) but things have snowballed. I currently have so many other (mostly uncompensated) responsibilities (medical director, electronic health record champion, running the Highline Urgent Care Clinic, chair of the Director's committee, quality committee) that handing these things off to other people has probably taken 40 hours a week by itself and underscores some of the reasons why I was feeling pretty overwhelmed and ineffective.

Then there's the patients. I'm touched, mostly, that so many of them have expressed so much regret that I'm leaving. Within 3 days of mailing the letter explaining my decision, the remaining 6 weeks of my schedule were completely booked. People have brought me presents and cards, and some cried. I ran into a few at the airport (where many of my patients work) and one lady, a TSA employee, ran up to me, grabbed me and gave me a big bear hug, totally freaking out my wife. Almost everyone said some form of "I'm so happy for you, and I'm really going to miss you" and they seemed pretty genuine about it. I probably will miss 75% of them but there's a sizeable minority whose lives are so chaotic, whose problems run so deep, that I have this enormous sense of relief at finally extracting myself from their misery. We did find a replacement doc who will start working the day after I leave. I sure hope he's comfortable with chronic pain, self-inflicted disease, and mental illness. How did I attract so many of these people?

Yes, I'm pretty exasperated with this place. I've been trying not to let it show, you know, not burn any bridges. My medical group is mostly filled with good people who serve a really difficult population within a health care system that is totally failing. But it's been hard.

I recently posted at Metafilter about the sorry state of primary care in the U.S. and I personally don't know how much longer I will hold out. I mean, I'm pretty excited about my new job and feel like it will definitely be a more effective organization, and I love practicing medicine, but I am skeptical I will last more than five more years practicing full time unless, by some miracle, there really is sweeping change in health care that is strongly favorable to primary care.

Which makes it really important that I pay off my loans in the next five years. I am currently writing applications for government loan repayment in exchange for a commitment to work with the poor and underserved. If any of that comes through, and with some frugal living, I will hopefully be rid of that ball and chain. And not having to make that $2100 payment every month for the next 20 years will really open up my career possibilities.

Although I am making contingency plans to get out of medicine, I wouldn't say that going to medical school was a mistake. I mean, I have skills that will render me a useful, employable member of society just about anywhere in the world. But things have gotten so bad in primary care that I'm simply not willing to shoulder the ever increasing burden of an inadequate system on my back indefinitely. And that realization has actually been very liberating.