Wednesday, July 21, 2010

Wednesday Morning Workday

Wednesday is the hump in the middle of the week. If I can get through Wednesday I'm on the other side of the work week. Wednesday I go to a street clinic where it's mostly general medicine and addiction medicine. This kind of work is predominantly 'doing' work. There's immense amounts of government defined paper work. It's mostly filling out prescriptions. The focus is limited. There are really good people who I work with. It's another fine fellow's clinic so I'm not in charge. The work is raw. It's not nearly as complicated in some ways as the work I do in my own clinic. Partly that's because the people are younger with very specific diseases as opposed to the vague and amorphous diseases, mostly psychosomatics, I see in my other practice. It's physical medicine mostly. There's psychiatry too but more at the 'brain' disease level rather than the 'mind'. I see immediate results or at least know that my 'regimented' response is what it's 'supposed' to be. I don't feel the 'weight' of 'curing' that I feel in my own practice. I don't have that co dependency sense that comes with one's own practice and long term patients referred who have been to so many other people. In this clinic it's apparent that the patient or client as one is called is the rate determining step and we are there to offer resources and provide encouragement but it's not like the wrestle with the devil that goes on in long term psychotherapy. It's really like family medicine. I feel alot like I did when I was a country gp and it's a good feeling. The work is 'different' in that way and 'refreshing' as a change. It's far more busy. I see 20 patients in an afternoon as compared to 5 in my own clinic. There's not the intensity that comes with the longer contact but over time there's the familiarity which comes with repeated brief meetings. The efficacy is achieved in a different way but it's clear that there is good work being done. Every day there's a very clear reason for being there. Some life actually gets 'saved' in a kind of way that's different from my own clinic where I usually think I'm pulling logs out log jams to get the person back in the flow or perhaps re directing them or getting them off a bad detour. In this clinic some of the people are climbing in and out of the abyss and it's a bit like being a medic in a war zone. You don't really get to have much say in whether they go over the top of the trenches and enter no man's land but you're there to bandage survivors and point them out of the fray.

I kind of look forward to Wednesday. Because of my afternoon clinic my morning is fixed with on going therapy patients who aren't likely to present major surprises. I've only a couple of hours and can't go over time and am often alone without staff. So commonly the patients that come in on Wednesday are higher functioning and less threatening.

The new unknown patient is the most threatening. Referrals that have waited months to see you and come through the door as unknown powder kegs. Just getting a history from a suicidal crack addict is a struggle and so many emergency level decisions are needing to be made in too little time. Yet so many patients are no shows for referrals that you can't book long time slots on the first visit because you only get paid if the patient shows. The 'no show' rate is highest in the drug and alcohol crowd and mentally ill and unemployed. Yet that same population is such an unknown. I feel like I'm alone in a psychiatric emergency at times seeing the patients that I once saw surrounded by staff. Maybe it's because my life has been threatened too many times and I've had too many people suddenly tell me they're going to kill themselves now. And I'm always afraid I'll miss something in the silences.

I don't. I'm surprisingly well trained and experienced, so wearisomely experienced but there's so much political pressure on one to please everyone and any word you say can be taken out of context by a person angry with the world looking for somewhere to rest their anger on. And so many patients are so angry and entitled today and as usual they often have hidden agendas. It seems a day or week doesn't go by that I'm not trying to save a life or diagnose or cure when I get presented with the real reason for the visit 'could you sign this note for my employer', "I really just wanted oxycontin", "I don't really have any illness, but my insurance company says I have to see a doctor." There are signs up all over saying that paper work should be given to the staff but the patient figures they can best get their needs met by presenting this 'form' at their own timing. It's invariably too late to do anything and then they're angry that you can't complete a 'book' of writing that's not paid for by any agency and they don't think they should have to pay for you "just to write a letter' and it's a battle, an ugly battle where you suddenly are the bad guy because the patient doesn't have money and wants you to work for free because they pay taxes but the taxes don't pay me.

And there are 10 million agencies and a billion people employed to destroy doctors and they are all in the 'business' of medicine with no responsibility for the 'life and death' issues but love 'advocacy' and all that military stuff and the doctor is the enemy and these forces are always poised to bring their batallions to bear on your little practice where you are just trying to do your best with every form of safeguard known to man and decades of advanced educations and mountains of laws over your head. And you're supposed to please psychopaths and crack addicts and psychotic people and you're afraid alone and trying desperately not to upset a person who you don't know who came without any of the past information of assaults, jail time or asylum time or even just on drugs that make them paranoid and youre' the object of their paranoia this minute and the waiting room is full and you're on a schedule and they're shouting at you.

Thankfully that happens only every month or so. It';s weekly at the other clinic, people shouting because they're asked to wait. But there there's more of us.

It's strange.

The truth is that the vast majority are what you work for. You love to work for the many. It's good. Wednesday is a good day too.

I like wednesdays.

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