Old joke

Complaining about a billing procedure the medical group I practice with has recently adopted reminded me of a joke my father once told.

My complaint was about the practice of marking up the price of a laboratory test to the patient, sometimes as much as a hundred fold, over what the laboratory charges our practice. The patients who actually pay this price are the ones with no health insurance as insurance companies will discount these charges. Stating that I felt this price gouging to be illegal, one of my colleagues, who happened to be the obstetrician that delivered my children, told me emphatically, "No, it is not illegal!" His tone and demeanor led me to believe that this is a common practice of his office as well.

"Well, if it is not illegal then it is immoral," came my reply. "Which reminds me of the difference between illegal and immoral. An ill eagle is a sick bird."

All nighter

It's into bed for me. Ten PM is early but this is a call night. Just as I am drifting off to sleep my beeper, clipped to the waistband of my pajamas, vibrates. Looking at it I reach for the phone at my bedside and call the number. It is a patient in early labor.

With the first patient heading toward the hospital, the second page jiggles. Someone has a urinary tract infection that will not wait until morning. The frequency of urination is too much. "I am not able to sleep!" the woman complains. I wait while she searches for the phone number of a pharmacy that is open all night. As I dial this number my beeper is buzzing again. The all night pharmacy has a message center however I know better than to leave a message there. Past experience has taught me that the patient will go straight to the pharmacy to get her pills. The pharmacy tech only checks messages every hour. I wait on hold to speak directly to the pharmacist to avoid a second call from this patient.

Fumbling with my beeper and the button to light the screen, I see a call from another patient who could be in labor. Finally, I am speaking to the pharmacist careful to leave not only a prescription for an antibiotic to treat the cause of the bladder infection but also medication to stop the burning so the patient can sleep.


Dialing the next number in my pager I am thankful for the lighted dial on the phone but wish I also had a pen with a flashlight attached. Now everyone in my household is asleep.

"I think I am in labor," the patient on the other end sighs. Experience has taught me that laboring patients normally do not sigh. They pant because they are slightly breathless. Women in labor have tight voices. I hear them anticipating the next contraction.

"How far apart are your contractions?" I ask.

"Well, I have only had about three," This patient sounds bored.

"When did they begin," I inquire.

"Well, I had one when I got home from work, another when I was getting ready for bed and I think I just had another one."

"Is your baby moving?" I patiently ask.

"Oh yes!" the voice on the other end brightens as of this is a sure sign that delivery is imminent. "She is always very active when I get into bed."

"Are you leaking any fluid."

"No. No, I don't think so."

"How about vaginal bleeding or discharge?" my inquiry continues.

"Nope, no, none of that."

Having exhausted my list of problems that need an intervention I ask, "Did Dr. H talk with you about labor?"

"Yes, I remember she did. I even have a little piece of paper here. I think she said something like 5-1-1?" the patient remembers.

"Do you remember what the 5-1-1 stands for?" I patiently ask. My beeper is vibrating again.

"Uh, oh, yeah, five minutes apart, lasting one minute for one hour. Do you think she wanted me to wait until the contractions are five minutes apart and lasting one minute for an hour before I called?"

"Yes, I do," comes my tired reply.

"What should I do now?" inquires the all too energetic voice.

"Try getting some sleep." This maybe wishful thinking on my part. "If you body gets too tired then you can't go into labor." I actually believe this and encourage women in the last month of their pregnancies to get as much rest as possible rather than walking, cleaning house or whatever to try and make themselves go into labor which almost never works and just leaves them too tired when labor begin.

"Oh, OK. You know, Dr. H told me I could take a Tylenol PM but I have never done that. Do you think it would be OK?"

"Absolutely!" I, the little known partner of the doctor this woman has been seeing for several months on the other end of the phone answers.

"OK. Well, when do I call you again?" She sounds less sure.

"When your contractions are five minutes apart, lasting a minute each and they have been that way for at least an hour OR if your bag of waters breaks which is usually a big gush of fluid." I remind her. Then I ask, "when is your next appointment."

"I am seeing you in the office tomorrow at 9 AM." she replies too cheerily. "Dr. H is on vacation."

Well, I forgot or maybe I never knew. Ignorance is bliss, right? "OK, I think I will probably see you in the morning. Good night," I reply.

"Good night. And thank you for talking to me." she redeems herself with the thank you. My beeper is vibrating again. I am two calls behind.

The rest of the story is that the first patient is in labor. I get up and dress, picking up a book on the way out the door. The beeper, cell phone, the book and I move to the hospital. I talk to another patient, one who is worried because she had some spotting after intercourse, while I am on my way. She is reassured by the time I arrive at the hospital.

After talking with the laboring patient and her husband, I write some orders in her chart and lie down in the call room. Getting comfortable, I realize that the call room I have chosen shares a wall with a room where the laboring patient is completely dilated and pushing to deliver her baby. "Push, two, three, four ..." up to ten, the dad's voice booms out. He stops at ten and there is a two minute break where all I hear is giggling. I am tired. Too tired to look for another call room. I close my eyes and I am lulled to sleep by "Push, two, three, four ...."

The call room phone rings. My laboring patient thinks she wants an epidural. She has talked to the anesthesiologist but she wants to speak with me again. Going to her room we discuss all the pros and cons both of us can think of just as we did in the office a month ago. While we are talking her contractions become even stronger. Now she cannot get the epidural fast enough while I am thinking I should have just stayed in bed for another fifteen to twenty minutes and then her pain would have made her decision painless for me.

As the night wears on I continue to go to bed and get up again until about 3 AM when the laboring patient is completely dilated. She begins pushing. I push with her for about thirty minutes and then go lie down again to gather some strength for the delivery. Setting the alarm on my phone, I get up after 45 minutes. The babies head is beginning to crown with a small about of dark brown hair visible at the opening to the birth canal. In addition to the patient, her husband and the labor nurse, her mother and mother-in-law are now present in the room. Of course all are excited. I even find myself getting excited as we see more of the baby's head. We all push together for about thirty minutes before the baby is finally born.

Lucky for me this is a vaginal delivery which I managed without an episiotomy. No lacerations occurred. I deliver the placenta and make sure that the uterus is firm, the cervix and vagina are intact with no injuries from the birth. Cleaning up the delivery table and doing the paperwork, I congratulate the patient and her family.

"You labored all night. Be sure that you get some rest." Leaving by an east door I notice the sun rising. I wish that I could take my own advice.

My beeper is going off again. It is a patient with pelvic pain. I could ask her to go to the emergency room where she would spend five hours getting the necessary tests. Instead I ask her if she thinks that she can wait three hours until the office is open. There the testing will take thirty minutes. "I can wait. I just woke up and thought I needed to call."

"You slept all night?" I am astounded.

"Yeah, I have had this pain for two weeks but it is not going away." came her reply. "I was worried and called your office yesterday but you didn't have any openings today so your office schedule an appointment for tomorrow but I am leaving on vacation tomorrow night and I was worried I would miss my plane."

Looks like another twelve hours for me. I had better go home, change clothes, eat, and hope that the rest of the day will be routine.

Holiday weekend

As an obstetrician my most difficult days are holiday weekends on call. These typically begin with calls from patients who have been trying to go into labor all week. Patients who know their own OB will be off for the next three days and they can't bear the thought of delivering their baby without him. Some of these patients actually make it in to labor, usually after their physician has left town. When they labor, the obstetrician on call delivers the baby and the patient is happy feeling so much better in her un-pregnant state. In these cases the on call obstetrician will be the hero by virtue of the fact that she drew the short straw and was the one who remained.

Of course there are patients who don't go into labor, many of whom are miserable near the end of pregnancy. Some of these women need to call and explain how terrible they feel. If these calls are between the hours of 7 AM and 10 PM and my family has left out of town for my weekend on call, these needs are easily met. I do what I do most days. I listen to the complaints, many of which come under the heading of "discomforts of pregnancy." Included in this category are maladies like indigestion, swollen feet and ankles, heat rash, and insomnia. Asking a few pertinent questions to determine there is no emergent need for the patient to be seen, I give her reassurance about the normalcy of her pregnancy along with tried and true home remedies for alleviating these discomforts.

What I do not do well with are calls at 2 AM and especially those that begin, "I have had this problem for the last two weeks and ...." Hearing this my first thought is "Well if this has been a problem for two weeks, why on earth did you not call your physician, who knows you much better than I, during daylight, weekday office hours for his advice and treatment." I never verbalize this however.

If an symptom that prompts these emergency calls in the middle of the night has been present for more than twenty four hours, I usually begin with, "What about (name the symptom) has made you call me now." The answer will usually fall into one of two categories. The symptom has gotten worse. Or, the most likely reason, at night the patient has time to think more about this symptom and how long it may have been there. Her thinking is compounded by the fact that she found out yesterday her mother's youngest sister, was diagnosed with breast cancer and she fears that she may have the same.

Again, if this is not a true emergency, I try reassurance and a promise to get the patient into the office as soon as the schedule will allow. If there is a need for someone to be seen in the emergency room for a gynecology complaint the wait can be a long one. The number of true emergencies rises as the holiday weekend wears on. More traffic on the highways and lakes along with increased consumption of alcohol will put ER space at a premium.

So, as the holiday weekend approaches, I have stocked up on message pads. I have two books to read and a movie to watch if I am stuck at the hospital with laboring or emergency patients. I have been playing classical music since I arrived this morning. And I could be pleasantly surprised with opportunities to do yard work, rearrange the den furniture and walk the dog between hospital rounds, deliveries and phone calls.