The phrase "World Famous in New Zealand", slogan of L&P soda, applied to Winton this week. National news picked up the story of "Whipper" the mutant budgie. An open house for the odd bird made the national telly news programs, as well as being picked up by all the regional newspapers. Liz has been enjoying her two weeks off for Easter School Holiday, walking daily with Vicki, shopping for a dress for the "Ball" coming in June, and just lazing around the house. While they've had fun spending "dad's hard-earned money", I was on-call over the last weekend in Invercargill. This involved working at the Urgent Doctor clinic. On Saturday, I saw patients in the office from 0930 until 10 pm, with a 1200-1400 pm lunch break and an 1800-2000 "tea break". On Sunday, my relieving doctor and I swapped places, and I worked in the office during his breaks. On Sunday when I was "2nd call" I was also on call for home visit, but there weren't any. During my time between breaks I drove down to Oreti Beach and to one of the local forests for some walks, and spent an hour in a cafe with a chocolate milkshake, and a good book ("Quicksilver" by Neal Stephenson). Best thing was being able to go home both nights, when the "3rd call" doctor comes on and takes phone calls and makes home visits. I can't complain at all- this was my first weekend call in about 3 months. I could really get used to this!
One of the things I did during Sunday's "slack time" was compile an analysis of my practice in Winton. I want to apply the 80:20 rule to improving my practice here, so I need to get a good handle on my case mix. I'm applying the principles we taught in our PBLA workshop at the Atlanta STFM conference last year. One of them is to analyze your practice by simply keeping a log for 100 consecutive patients. I kept a log on a piece of graph-paper for each half-day, recording diagnosis and age bracket using hash marks. The half-day logging works well because you can quickly tally up your visits, and if you made an error, you haven't blown the whole week. During my slack time on call, I summed the talleys, and now I've reentered them into a spreadsheet. In order to have something to compare to, I cut and pasted data from the National Ambulatory Medical Care Survey on the CDC website.

Be SURE TO Click on this link to see the spreadsheet and charts, which show my practice here at a glance.
Here are some of the important points I noticed after doing this:

• There are NO well-child visits. Well, I only do newborn checks a few times a month next door at the birthing center, and an occaisonal 6 weeks check. All the rest of the visits are done by Plunkett nurses for the most part.
  
• There are not a lot of diabetes management visits. I'm not sure why. I see a fair number of diabetics, but most are under control it seems, and most are coded in my sheets as "hypertensive" because that's what need managing. It may be because almost all of them receive free yearly diabetes checks and are co-managed by GP and specialty clinics who both see them regularly.
  
• Everybody seems to be hypertensive. That is why there are no "lipid" visits- I'm working on the hypertension and the lipids simultaneously, and most patients have controlled lipids and uncontrolled HTN
  
• Only 1/4 of my HTN patients are controlled. The chemist has noted my agressive dosage increases.
  
• There are not a lot of sore throat visits. Most patients here are wary of antibiotic overprescribing, and I notice little demand for antibiotics for URIs.
  
• There are very few visits for neurosis (anxiety) and depression. Patients are also very wary of antidepressants.
  
• There are a TON of primary dermatology visits. I don't know why this doesn't show up in the NAMCS surveys (or why the other common diagnoses on the right of the graphs are not seen frequently by "General/Family Practice" doctors surveyed). They are a WIDE variety of problems: acne, allergic rashes, changing moles, ingrown toenails, lumps and bumps, lots of BCC and SCC type skin cancers, head lice, scabies, etc. This reflects my U.S. experience as a rural doctor also. Note that I did NOT include the 7 patients seen and treated at the Wednesday evening "liquid Nitrogen" clinic in my talleys.
  
• Asthma and CHF are common problems here that patients are used to managing with regular visits. One of the advantages of the "free" medicines under Pharmac is that patients are motivated to come in every 3 months for prescription refills. There are no inhalers "over the counter" such as Primatene Mist, and the chemists here are really good at educating patients about disease management also.
  
• This was a "light" week for injuries, so they may be underrepresented in this talley. However, the Practice Nurses here in Winton are superb when it comes to wounds, and only wounds needing suturing are generally booked into my rooms. Wound infections, dressing changes, and wound monitoring are the daily business of the nurses, and we doctors see these patients in a supervisory capacity to the nurses. This is probably about 5-10 patients that I see with the nurse daily.
  
• Adding up the nurse supervision (conservatively) at 25 patients a week, plus the LN clinic of 7 plus my 96 yields a total of 128 patients in a week, which seems about right.
  
• The age distribution explains some of the reason this seems a lot of patients. The schedule is heavily geriatric. About half of the ">71" patients are actually over 80 years old. As a new locums, trying to see a complicated older patient in 15 minutes is fairly stressfull. It has only gotton easier these last few months, as I've gotton to know a lot of the "regulars". I remember in my first practice how things suddenly seemed to get a lot easier after I'd been there 3-4 years and knew the patients well. I do think having a well organized EMR here is a great help to quickly getting up to speed on an older patient- especially for managing those long lists of medications. Its hard to believe I used to handwrite all those long geriatic med lists.