Saturday, November 17, 2007

Standing my Ground

So, alas, all good things must come to an end, and I am on call once again. I am taking call for OtherDoc, as well, not only for the weekend but until I leave town for Thanksgiving on Wednesday; he is on vacation this week. I know that I have bitched multiple times over about how very much I dislike taking call for his patients, but get ready to hear some more.

I think, scratch that, *know* that the man is seriously overburdened with patients (60-80/day!!) and I am quite sure that I wouldn't know my own ass from a hole in the ground if I were that busy, but he lets his patients run his life...and now they are trying to run mine. He is more than, shall we say, liberal with narcotic pain medications. Aw, face it, he hands it out like candy! It never fails, as soon as I take over his calls the pages for narcs begin. I can't stand seeking. It truly makes my blood boil, but I calmly state that I will not prescribe narcotic medications to patients that I haven't seen or examined personally. (Even then I rarely give narcotic meds, truth be told.) You should hear the stories, and if you work in the medical field, you probably do. Today it was, well OtherDoc gave me a prescription for (name your favorite narc here) and said I could have a refill, but he didn't mark the refill, so you just need to call it in (sic!). Ummm, sorry honey, but no. I'd be happy to call you in some Nap.rosyn for your pain until you can get to the office to be seen, though. Silence...then click. Sigh.

Even better still, OtherDoc had scheduled an elective term primip for induction of labor earlier in the week. The reason for induction? Well, because he was going out of town, of course. Labor and delivery has been insanely busy, so this elective induction got bumped, not once, but twice due to people being in actual (gasp!) labor. The news, each time, was met with shrieks and screaming at our office staff and labor and delivery, but there was nothing that could be done to accommodate her for her very elective (and early, at 38 weeks) induction.

The patient then decided that she wanted me to induce her on Monday, since I was covering OtherDoc. Never mind that I have never once met this woman nor examined her. Never mind that I truly don't *do* truly elective inductions because of the risks associated with them. *She* had already started her disability leave from work, thus she needed to have the baby now. (Priorities much?) Other Doc actually tried to guilt me into doing it, too! Her due date isn't even until the end of the month!

Could you just imagine, should the induction go awry, the cross examination? Dr. Whoo, why was this induction scheduled? Oh, the patient was tired of being pregnant? Hmm, that's not an ACOG approved indication for induction. Had you ever met this patient prior to *pumping her full of drugs to hasten a premature delivery*? On and on and on! Oh, by the way, drop your license at the door on your way out. I'd be painted in the media as "just another doctor" trying to screw up how women give birth. ('Cause, you know, all evil OBs really want to do is c-sections...all the better to ruin your "birth experience" my pretties! Cackling! Evil! Laughter!) But, I digress...Guess what my answer was? That's correct! It was a resounding "No!" I will be seeing her for an office visit this week, however, if she decides to show up. We shall see.

I am disconcerted at how browbeaten I feel by patients on such occasions. It shouldn't be so antagonistic to practice good medicine. One of my favorite attendings used to say, "This isn't Burge.r; you can't have it *your* way!" Only more and more often, it seems, you can! I fear for the future of my profession. Dr. Google-topia is closer than we think. Eep.

In other news, Mr. Whoo and CindyLou are wending their way to the grandparent's house, far, far away. Bean and I will be flying to meet them on Wednesday, since I have very little remaining time off, what with maternity leave and all. Yes, I *am* taking call for myself and OtherDoc alone, with a baby, for four that crazy? I think, yes. Happy Weekend!


A Lupie Momma said...

You are nuts. He really sees that many patients a day? How on earth can he actually give them the time for a proper appt???

I have no sympathy for narc seekers. They give people who follow the rules of pain management a bad name. I am prescribed lortab for endometriosis and adenomyosis (suspected, not confirmed for the adeno). I have strict rules to follow. Start with 800mg motrin. If after an hour it is not working, THEN I can take a 5mg lortab. If it is really really really bad, if the 5mg lortab isn't working then I can bump up and take another 5mg tablet. I am prescribed lortab through my pcp, who copies my obgyn and endometriosis specialist on my records (one dr is running the pain management). I know that if I am running low, I need to call a week in advance so that I can have enough. My pcp would rather the pain to be controlled than to let it out of control. My scripts are not called in to the pharmacy (although if I was in a situation where I followed the above and it didn't work, she would call in something. She has told me before that I could go higher with something else if needed. However, I have not needed to bump to something higher), I have to come to the office and pick them up and sign for them.

I do have to say that since I started the plan with her, it has worked. No way would she approve if she is out on vacation and someone happens to call in. You have to wait till she gets back. That's why I have to call a week in advance.

Why on earth would ANYONE want to be induced? I have had 2 emergency inductions and wish that I could have gone as long as possible and had a NORMAL delivery.

Just remember it will be over soon. Soon you'll be with Mr. Whoo and Cindy lou with your parents.

Any possible way you can get out of taking call for the other doc???? My obgyn is private practice/solo dr. I assume he takes call for other drs (I know he does for the ER) but, whenever I had an issue, he told me to call him. I never had to call "the other dr". Does the hospital require you to take his call? I hope you can get out of it soon. I am sorry that the patients are awful. If they were truly in pain, they would do everything that you request of them and then some.

P.S. Just to let you know, I finally got a diagnosis last month from the endo specialist and it was endometriosis and suspected adenomyosis. Tried trigger point shots Monday. 2 worked. 1 didn't (the worst one/area). He said if it worked more than 24 hrs, it was in the muscle abdominal wall. If it was less than 24 hours, it was the endo causing it. His advice, get pregnant asap (we were planning to anyway). Then afterwards, have a hysterectomy and get rid of the uterus (I'll be done with babies after the next one anyway). Still have to decide whether to keep the ovaries or not, but that is a year away. I am so glad you are back and writing again!

Anonymous said...

Hooray for you for standing your ground and saying no to elective inductions! It's very reassuring to hear an OB expressing concerns about the risks involved.


Midwife with a Knife said...

Hooray for you for sticking up for your (and good obstetric) principles! :)

When I was a resident, we had an attending who would say to patients like this, "What if we gave the last bed to you for your elective induction, and someone else came in in labor and we had no place to put her?"

The sad part is, so many patients either don't care or can't understand this argument. It's all about what they THINK they need. And with the new data coming out about how mild prematurity may be a bigger deal than we think it is (it seems to increase mortality from all causes in the first 6mo of life, if I remember correctly)

Amanda said...

I hope you get a break soon. The pace you keep with work and family sounds insanely sleep-depriving.

Anonymous said...

I must admit, I use Google a lot. I found that way when I had that positive screen result. I think Googling helps a lot for calming fears, allowing me not to bug the OB about them. My OB's great, but I don't think she actually "got" how scared out of my mind I was at first. I could read, and found a forum to release my fears and thoughts without taking up time in the office for all that. Pregnant women still need the physical care, and the monitoring for health issues. Also, Google can do a lot, but it doesn't sort for accuracy. I have learned to tell what is incredible and what is right. However, I am always watching myself to make sure I don't think I am smarter than the doctor because of my reading. I do however think I was more aware of reality than my last nurse in delivery partly due to my reading online...she told me the best way to push was flat on my back even after I had heart decels early in labor, I was so scared the baby was at risk. Birthing books (even "What to Expect When You're Expecting") say pushing on your back is not optimal in most instances. All my Googling on that topic said it too. So, I was shocked (but having strong contractions and back pain and unable to fight when she moved the bed down) when I said I didn't think I should push on my back and she gave me some line about the baby going over my tailbone better. It wasn't until the OB came in, checked and found baby OP that I was allowed to push in different positions I had read about and baby came out in 10 minutes. I wanted to kiss him (not my regual Ob and he creeps me out because he looks like MR. Rogers, so wanting to kiss him was a big deal) but I was glad for his expertise and I respect him more than I did before. I knew enough to know he was right, wish my nurse did too! Google cannot make up for medical authority or medical school. Google does help you know there is more out there than just one opinion. Just have to be wise about it though.


Anonymous said...

I think patients are afraid their doctors aren't giving them choices or the full picture and that's why they Google. I know I don't trust some hospital nurses after my 6 birth experiences. I've had one not aware I was showing signs of baby coming though I said, "I feel baby's right there" and "ring of fire" and "my body is pushing." The baby came out with her back turned, warmer not on. I had been telling her for about 10 minutes I knew I was close, and for about 20 minutes to get the OB up to the room. I had a nurse this last birth not allow me to be out of bed for long. I had an initial 20 minute strip showing baby fine while I was up, and the nurse said I could only take a shower if she checked my cervix. She put me flat on my back and monitor read a decel. I sat up after she said, "no" and baby's rate went from 80 to 124 immediately. She still wanted me in bed. OB gave me permission to be up, but once the OB was out of the room, nurse had me on the bed. I was embarrassed that I fought her and sat up, and so I complied even when I thought it was dangerous. I begged to get out of bed, to go to the bathroom. She said, "no" and also said I was only feeling I had to pee because I had the head "right there." She had me on my back every 20 minutes to check dilation, and pushed my cervix back through several contractions trying to reduce a "lip." She said I was at 9 cm and had me pushing (and when I pushed, guess what, pee came out), but the OB told her to have me labor down. She did for another few minutes, and then had me pushing again flat on my back. She said, "you'll love the stirrups (yeah, right). I said, "are you sure I should be pushing on my back, I've had 5 babies sitting almost upright" she said, "yes, your baby comes over the tailbone better if your'e on your back." I pushed for an hour and a half (all other babies either came out with very few pushes, even my first was born in 15 minutes of pushing). I knew something was wrong, and yet I couldn't fight this nurse. She was very authoritative. Finally, OB came and found baby was OP. He had me get up and move positions (he left the room thinking it would be a while as baby was "up high" not right there keeping me from peeing). I had baby 10 minutes after he left the room. All along, I needed to be moving not in the bed on my back or just on my side (for some reason being on my side didn't help ONE decel, sitting up worked though). I really was afraid for my baby every time the nurse put the bed flat, and when I pushed and baby didn't come out I feared a c-section. So, next time I have a baby, anyone who cares for me may have to deal with my questions and I may stand up for myself more. I will seem like a bad patient, but the nurse's actions really scared me. I'm actually considering going to a midwife rather than my OB again (I never get her for the birth anyway, and have had the baby with only nurses and my husband in the room the last 3 babies anyway). I am looking into a birth center. I just feel being vulnerable in labor causes me not to stick to what I feel is best. The nurse suggested I was not considering the health of my baby for a birth plan, but in reality, I felt what she was doing was risking O2 to my baby, flat on my back so much. I will say though, I have never had a nurse be so bossy before. Most are amazing angels.

So, maybe it's patients' fears of the medical profession that causes them to seek Dr. Google so much. Again, I think it's important we are careful what we believe from Google.


Anonymous said...

Wow. I'm sorry. As an experienced mom of four and certified grandma-wanna-be, I'd come and hold your baby for you while you got stuck with all that, if I could. Do have a wonderful Thanksgiving, and may all those patients not have their babies while you're on call this week.

Cindy said...

Wow, how do you do it? I work regular hours and feel like I'm losing my mind coordinating daycare with an infant and a toddler!

Anonymous said...

'Cause, you know, all evil OBs really want to do is c-sections...all the better to ruin your "birth experience" my pretties! Cackling! Evil! Laughter!

Ahhh I see you've been to ICAN lately... snickers, ducks and runs.
Stand your ground. You sound oddly human, and I mean that nicely. I usually don't hold much for OBs... you sound a bit more like a walking poster for what they 'should be'.
Someday, cause I know you have so much time, could you elaborate on elective c/s's... perhaps your stance on vbac? Seeing as North America is looking at 1/3 of women giving birth surgically.
Yes, I'll happily wait until next year for a response =)

Dragonfly said...

Hope it all goes well. It can be hard to be the one doing the right thing, particularly when some jackass has set a precedent of being a soft touch for drugs. Not long till Wednesday.. (well, here at least that is with a different time zone).

Anonymous said...

Goodness! I had no idea people could behave this way? I'm not in the medical field. I hope call gets better for you. You sound like a great doctor!

Anonymous said...

You know, my sister has a bunch of girl friends out in Denver who are having elective c-sections or planning inductions for convenience. I know I'm not one who can really judge here, since I've not had a baby and likely won't for a little while, just seems weird to me. I'm sure it's even weirder for you! Hang in there, and happy turkey day!

Anonymous said...

Dr. Whoo,

Sorry for ranting AGAIN about my nurse during my labor. I shouldn't do that here! Moderate away.


Julia said...

I hope you survived your call!

And yes, I have to say, this demanding, antagonist behavior by patients can really wear you down. Good for you for sticking to your guns!

Anonymous said...

First, just wanted to say that I love your blog--I'm an avid reader.

Second, I was just curious about the drug-seeking thing, since it's something that has come up in previous posts. I can certainly understand how drug-seeking would be a huge put-off for you, but have you considered that it is possible that some of these patients who call you asking for pain meds truly are in pain? Obviously it's none of my business how you treat your patients, and I don't mean to sound judgmental. It's just that there was one occasion in which I was forced to call my ob/gyn one evening to ask for pain meds, and I don't know what I would have done if she hadn't called in anything for me. I had had an endometrial bx performed, and for some reason, the cramping was incredibly intense and wouldn't stop. I'd tried every OTC pain med, and nothing stopped the cramping. It was so intense that I was breaking a sweat and hyperventilating. (And just so you know, I have a pretty high pain tolerance--I didn't even fill my script for Vicodin after I had my wisdom teeth out.) I guess I could have gone to the ER, but my financial situation was tight as I was in college at the time.

Anyway, my doc called in 2 tablets of Tylenol III, which were a godsend, and I had a f/u appt the next day. With prescription drug abuse at an all time high, I guess you have to be cautious w/ your prescribing habits--it's just a shame for the patients who have legit requests.

Anonymous said...

Hi! Found you at Not Afraid to Use It. What is correct etiquette when formally addressing a doctor and her husband. Is it Mr. and Dr. Whoo? Dr. and Mr. Whoo. Mr. and Mrs. Whoo?

Just curious.

Not Afraid to Use It said...

Did the patient show up? I am dying to know if she had the audacity to treat you like that to your face. I hope it is going better for you this week.

dr. whoo? said...

pe mommy~ I have no idea how the man does it. I do know that patients usually wait up to 3 hours in the office to be seen. He's a nice person and a decent doctor, but I'm not certain that he's worth that kind of wait! Maybe it's worth it for the narcs he writes out?

As for getting out of taking call for him? I waited a whole year to get to share call with him! If I don't take call for him, then I am on call 24/7/365 with not even a measly 4 days off per month. As much as his patients can suck, having a few days off and away from the pager is worth it. Personally I'd like to share call with more than just OtherDoc, but so far, no dice.

I'm glad that you have received the proper diagnosis and that the treatments are working for you. Good luck with the baby making!

JR~ Thanks. Contrary to popular opinion, there are quite a few OBs that don't do elective inductions, you just don't ever hear about them.

MWWAK~ Thank you! I did read that study about slight prematurity. Scary stuff since, when I was in residency, the consensus was that delivering a 37 weeker was totally "okay."

amanda~ Thanks for the well wishes! Fortunately for me, I don't require a whole lot of sleep. I have this weekend off, but is there really ever any true rest with an infant and a pre-schooler?

Dawn~ Wow, that's some mean labor nurse you had there! I think that Google can be good and bad, there just isn't a good filter between the good and bad information.

alisonh~ Aw, thanks for the offer! I hope that you had a great Thanksgiving, and that grandbabies are in the near future for you!

cindy~ Ha! My dad always says, "There's nothing to it but to do it." Honestly, I think that I lost my mind early in my residency. Sometimes that makes life easier. ;)

anon~ I'll take oddly human, but most OBs aren't close to the monsters that they are made out to be. Don't get me wrong, the bad docs do exist, but they aren't the majority. I don't do elective cesarean deliveries, but patients do request them more often than one would expect. I do VBACs and always offer them to my patients at the first prenatal visit, most all tend to elect toward repeat sections, sort of "the devil you know" phenomenon. So docs aren't the only driving force behind the rising surgical rates.

dragonfly~ Yea, it is frustrating. My nurse told me this week that one of his patients called this week for a refill of hadn't been seen in the office in 2 years. He gave it to her.

sc~ It is truly amazing how people can act toward their health care providers and staff. People are terribly rude to us on a daily basis. Sad. Thank you for the compliment! I am trying. :)

lara~ Yes, it blows my ever-loving mind! How is your sister doing with her pregnancy? People are so weird with scheduling things that shouldn't be scheduled. Hope you had a great Thanksgiving!

Dawn~ No worries, sweetie, rant away!

julia~ I survived! Woo! Thank you! I am quite stubborn in general, but in particular when I know that what I'm standing up for is right.

diane~ Hi there and thank you for reading! I know I sound inflexible, but of course I take into consideration legitimate requests.

Your scenario is a little different for 2 reasons: 1) your doc knows you and has a reasonable grasp on your history and 2) you had a recent invasive procedure and a valid need for pain meds. I know that OtherDoc's patients knew well in advance of his vacation, and those with need for meds for chronic conditions had suitable notice to get their scripts filled. He wasn't doing invasive office procedures pror to his departure, either.

I still don't prescribe narcotics as first line. I often offer Naprosy.n, which is a great pain med, especially for pelvic pain. Those in legitimate pain will take it; those that want to get high hang up on me. I also offer them work in appointments the Monday following the weekend, should Naprosyn not work. This way I meet and get to examine them in person before determining the need for stronger meds. At any rate, those with legit requests, as you say, do get care, they just don't get blind phone med distribution from me. So far, it has served me well! :)

cardiogirl~ Well, I don't have an Emily Post handy, but I am pretty sure that it is Mr. and Dr. Whoo in formal address. For close friends/more informal address Mr. and Mrs. Whoo is also ok. (Personally, I like to have the Dr. prefix addressed to me. I worked hard to earn it!)

not afraid to use it~ HA! Well, yes, she did show for the appointment, but I was in the hospital delivering a baby so we did not see each other. OtherDoc induced her when he got back in town. I understand she and baby did fine!

Masked RN said...

Just found your blog and have enjoyed reading. Refreshing to hear your point of view with care. Be proud of yourself.

Somenurse said...

Better late then never, I also just found this post.

"'Cause, you know, all evil OBs really want to do is c-sections...all the better to ruin your "birth experience" my pretties! Cackling! Evil! Laughter!"

I love this quote! Its true though, it is the common perception that needs to be fought. Keep up the good fight1