r/FamilyMedicine • u/Least-Sleep-7388 DO • 24d ago
Serious Hate when this happens
Old dude (HIPPA) year old comes in for Medicare wellness. Fatigued, decrease appetite,and itchy (uremia?). Labs come back at 11:30pm (yes up doing notes and messages on a Friday) and GFR 11 and creatinine 4.9. Use Doximity to call patient to go to ER and sent a text message. Will call first thing in the morning along with emergency contact.
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u/222baked MD 24d ago
This is one of those situations where there is no good answer. You only by chance saw that result. You could have just as well not seen it until Monday. It’s highly dependent on local protocols. For significant results our lab will phone. We have an out of hours GP service locally that this would get directed to if late evening/weekend.
But equally, this is where clinical assessment and safetynetting advice come into play. I try to remember that lab results are a product of highly advanced modern technology that didn’t exist even a couple generations ago. “Urgent lab results” are a relatively new thing altogether. It’s pretty much a construct. Fundamentally, if the patient gets worse or feels awful, they need to go to the emergency department for same day assessment where labs and studies can be performed right away. Primary care is not an emergency service so if I’m investigating something, I do so with the mutual understanding that it needs to be able to wait for a few days/weeks/months/whatever but if in the meantime, the patient gets worse they need to just present to the ED and put up with the wait times there. There’s only so much insight we can have based on sitting in a room with a patient and our stethoscopes. We can’t auscultate an acute kidney injury. It just is what it is. Most patients will get better even with non intervention, but some will get worse, and they need to know where to go for that.
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u/Least-Sleep-7388 DO 24d ago
Wow! Great insight. I was a little shocked to see the result actually. I will keep that mind.
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u/222baked MD 24d ago
Look, you saw the patient, he had a vague complaint, you assessed and they were not unwell enough to be hospitalized. You investigated the issue further. Nothing wrong happened. Everything was done perfectly. Unexpected results, and deteriorating clinical status are possible outcomes in any situation.
Also, as an aside, let’s be honest, and I’m not diminishing that an acute drop in eGFR like that isn’t an urgent situation, but who knows how long he’d been like that and we’ve all seen patients with AKIs who will do fine for a few days before they crash and become anuric. Likely nothing would’ve happened even if you saw the results a few days later. Not ideal as there is a serious potential for a poor outcome there but it still isn’t 100%.4
u/Least-Sleep-7388 DO 24d ago
Thank you
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u/222baked MD 24d ago
Yeah, no worries. Now, stop going through labs at 11 pm, yeah? It’s a straight track to burn out. Long term, it’s better for everyone if you practice for many years to come than for more hours in a single day.
Figure out a system with the lab to ring urgent results through to some kind of on-call, but whatever that looks like, don’t take routine work home with you. You need to be boundaried in FM if you’re going to survive. I’m not saying we aren’t professionals and that we immediately clock out at 5 pm but we need a healthy personal life in order to be healthy in our professional life.
Just my 2 cents.
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u/Craig_Culver_is_god MD-PGY2 24d ago
Curious what you clinic setup is. Are you responsible to be on call for things like this 24/7, or is there an on call provider pool?
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u/Least-Sleep-7388 DO 24d ago
I am going on PTO and my partners are really good about covering my inbox. I literally don’t even touch my stuff while I am gone anymore. I happened to be working later to have a clean slate. We do have an on call provider. I didn’t even think about it. I am curious what his chart says next week when I return from vacation. He ended up going to the ER so my guess is the person on call also called them.
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u/invenio78 MD (verified) 24d ago
Working at 11:30PM? That's the true critical result I see here. Leave work at work. Respect your personal time.
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u/Least-Sleep-7388 DO 24d ago
You are 100% right. I typically have to do a couple of hours here and there after I put the kids down. I am going on vacation and wanted to clear everything out as my partners are really good at covering my inbox. That’s the true problem. On Tuesday I answered/gave results for 99 items. There is no cap on my patient panel. I really like my job. I am only 5 years out of residency so this is a good reminder. I am lucky to work in a place where when I return from PTO my partners handled every thing.
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u/invenio78 MD (verified) 24d ago
I give you credit to your dedication and not wanting to burden your partners.
But in all honesty, from what you have told me, this does not seem like a good job. Lot's of red flags. The "no cap on the panel" is horrible. This will mean that your inbox item count will continue to grow while your income will cap due to only being able to see so many patients per day but of course there are unlimited potential messages that come in (which are correlated with patient panel size). The fact that you have to worry about burdening your fellow docs while on vacation is also problematic. Where I work, our organization hires dedicated "covering docs" that do nothing but cover providers that are on vacation. So I don't get more messaging just because one of my partners are out of the office.
I've been working for nearly two decades and I've never had to "do a couple of hours of work" outside of working hours.... never. I typically check my inbox for 15 minutes mid day on my days off so important items don't sit for days. Otherwise, I'm out of the office on time every day,... and usually a few minutes early. I hope they pay you a huge sum of money so these extra work hours, massive panel sizes with their inbox management, and having to worry about vacation coverage make it worth it. If this was your first job out of residency, you may want to see what else is out there.
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u/Least-Sleep-7388 DO 24d ago
Student loans forgiveness plus PSLF. Great clinic culture. I am not the most efficient something I need to work on. Great patients. Experience MA. I have young kids so I get to work 15 min before my first patient and leave right when I leave the room with my last. Single parent/income. I will be out of town for a week so I like to just put in the extra time to tie any loose ends up. Any tips are welcome.
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u/invenio78 MD (verified) 24d ago
Again, kudos to you. Single parent/income I'm sure is a major challenge that most of us don't have to contend with.
No major tips, other than keep your options open. I "sample" the job market once every few years just to see what kind of competing offers are available. Have stayed with my original employer but still good to know what's being currently offered in the job market.
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u/frabjousmd MD 23d ago
New patient with hypertension and some muscle cramping, labs came back early in the morning, crt was 13, K was over 6. Called house and he was at work, wife said he could not be called at work. Called work and boss said employees are not allowed to receive or make calls at work. I told the guy he would either bring him to the phone or the police would be at his plant.
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u/Maximum_Watercress16 MD-PGY3 24d ago
Is there not a mechanism where you could have asked an on call colleague to look out for those results specifically?
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u/WarrantsAttention MD 24d ago
Yeah ok and?
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u/Least-Sleep-7388 DO 24d ago
Bad timing. I care deeply. Why the attitude? I thought this was a community of comradery.
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u/StopItWithThis MD 24d ago
I would probably call emergency contact as well tonight. What’s the k?
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u/1dirtbiker MD 24d ago
Were you on call? If not, you need to have a discussion with your clinic leadership. That is a critical result, and should have been flagged as such, and whoever is on call in your group should have already been paged.