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Avoiding the Shoals of Contracts and Codes

from La Bohème and telling you you're going to burn in hell if you don't give them OxyContin. Don't fall for it."

In fact, during my first days on call, I got dozens of phone calls from people who said they'd just run out of Percocet, or the cat had eaten their codeine, or their ex-boyfriend had stolen their Valium.

"I had one guy who claimed to be on his way to his wedding," another colleague told me. "He said he had a kidney stone and he'd had them before and could I just give him some Vicodin to control the pain during the ceremony. And I was actually writing out the script when I realized his tux didn't fit. Nobody gets married in a tux that doesn't fit. From there the whole thing unraveled. But I tell you, I was this close."

"But some people really do have kidney stones," I said.

"Don't give out anything unless you are holding a positive CT scan."

"I had this nice young woman come in the other day with kidney stones," I persisted. "She'd had them before . . ."

My colleague looked at me knowingly. "Let me guess. She was allergic to contrast dye so she couldn't have a scan, or, no, it was under her deductible and she couldn't afford it."

My eyes widened. "There was blood in her urine," I said.

"People prick their fingers."

"I think she really had stones."

"Talk to me in three months."

In three months, the "nice young woman" had come back to me four times for refills of narcotic painkillers. I pushed her harder about getting a scan, or at least obtaining old records documenting her disease; even assuming her story about the kidney stones was real, I didn't want to miss a diagnosis or treat the wrong thing.

She responded with a scathing letter saying that I was hateful and mean and shouldn't be allowed to see patients. Then she started calling when other docs were on call, telling them an untrue story about how I'd put her on stronger painkillers than she wanted and asking them to phone in a prescription for "something milder."

Happily, at last, I came to see the plethora of advice as a blessing as well as a curse. If there was no right answer, I couldn't be expected to have one. As the months went by, I realized there was a balance to be struck between cynicism and gullibility, between offering too much and believing too little.

When the prescriptions dried up, she left our clinic.

I also got advice about managing calls on nights and weekends. "Send people to the ER," one colleague said. "You get someone calling in the middle of the night and you can't figure out for sure what's going on, just send them in."

"Don't send anyone to the ER unless you absolutely have to," another advised. "New docs always think that 'Worst comes to worst, I'll just send them to the ER.' But then you'll be getting calls fromthe ER docs at two in themorning to say, 'Hey, your patient is fine,' or, worse yet, 'They seem okay but they're here so I've decided to admit them, so you'd better come in.'"

And there were recommendations about managing my staff, my schedule, my office, my colleagues. "Be flexible," some people told me. "Say yes to anything anyone asks you to do; you can always scale back later." "Set firm limits," others said. "Once things spiral out of control you can never get them back in."

Some people recommended having a high threshold for referring patients out to specialists, others a low one. Everyone had a horror story from starting practice that they wanted to share. One had gotten so busy so fast he was overwhelmed and ended up being hospitalized with anxiety

and depression. Another left her first job because she'd felt ostracized for refusing to work late hours.

"Play the game." "Don't be too nice." "You can spoil everything by taking the wrong steps at this stage in your career."

Then there were the conflicting instructions from our patients' insurance companies and from our malpractice insurer. Be efficient, we were told; the insurance companies are counting every dollar you spend. Be complete, our malpractice carrier told us; leave no stone unturned or you'll be susceptible to a lawsuit.

One day we had a long meeting about how expensive transcription was and how all the doctors in the clinic would have to cut down on the length of their dictations. The next day there was a riskmanagement meeting to inform us that if we didn't document every thought in our heads and every detail and nuance of each conversation with our patients, we were liable to get sued.

"This is crazy!" I complained to a friend from residency. "It can't be done."

"My office had those same two meetings last week," he said.

Every word of advice was well-meant, and undoubtedly the inundation seemed more ominous to me than anyone intended. People were only trying to prevent me from repeating their mistakes. Still, with every hour bringing a new piece of wisdom, each one contradicting the last, I was exhausted and confused. The message seemed to be: There is no way to do it right.

Happily, at last, I came to see this as a blessing as well as a curse. If there was no right answer, I couldn't be expected to have one. As the months went by, I made some mistakes and averted some others. There was a balance to be struck, I realized, between cynicism and gullibility, between offering too much and believing too little. There was usually a line of reasonable medical judgment that fell somewhere between spending a fortune to eliminate all uncertainty and saving money by accepting too much uncertainty. There would be pieces of advice I would take and pieces I would ignore.

Despite everyone's desire to help, I would have to find my own way.

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Transue, an internist in Seattle, Wash., is a 1996 graduate of Dartmouth Medical School. She began writing patient narratives while she was a student at DMS as a way to process the emotions of medicine. Many of her stories have appeared in Dartmouth Medicine during the years since then. She is also the author of two books published by St. Martin's Press—On Call:A Doctor's Days and Nights in Residency and Patient by Patient: Lessons in Love, Loss, Hope, and Healing from a Doctor's Practice. This feature is excerpted from the latter book by permission of St. Martin's Press, LLC; it is copyright 2008 by the author.

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