Job offers and Sisyphus

Call brings me no compensation

I struggle with documentation

I might sound like a boor

But our EMR’s poor

And a source of great irritation.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

 I’m starting to get wanderlust again.

Most days bring 6 to 10 job offers, some permanent, most locum tenens (temporary or substitute).  I look at locations and I fantasize.

Places interest me.  A spot in Wyoming evidently has terrible problems recruiting, I’ve received very good offers for the last 10 months.  Indian Health Service has a trouble filling positions as well.  Veterans’ Administration, Armed Forces posts, and Bureau of Prisons chronically seek physicians. 

The one that piqued my interest the most this week was Nome, Alaska, partly because I just finished Michener’s Alaska and partly because I worked in Barrow.  I wouldn’t really take the job because they want Family Practice with Obstetrics, and I swore off delivering babies on May 7, 2010.  Nor do I want to work more than 2 air hours from surgical backup.  Still it looked like a really, really interesting gig.

Ireland keeps sending me information about “hot jobs.” 

I have no interest in cities, not even exotic cities like Albuquerque or San Francisco, though I might consider something in the Denver area because of family and friends there.  For some reason Wisconsin has fallen completely off my radar screen.

I don’t much look for pay rates; still I’m impressed by some of the figures I see.  Bottom lines upwards of $300K come occasionally, but what really catches my attention are the offers of extra money for taking call. 

Bethany and I had such a great time in Alaska in the winter and New Zealand in the fall. 

While I can still remember the absolute euphoria of coming home and seeing familiar faces and sleeping in our own bed, I can feel myself starting to find fault with my current job.  I have begun to dwell on the call for which I receive no compensation and the hours of documentation I do outside of work hours.  The electronic medical record system (EMR), horribly inefficient to start with, irritates me more and more every day.

And if I miss too much sleep I find judgmentalism creeping into my thoughts.  Hospitalizing the same people for the same problems (which come down to bad lifestyle choices) makes me feel like Sisyphus. 

Yet I really enjoy my coworkers, the morale of the clinical staff runs consistently high, and I like doing hospital work.  A lot of docs don’t.  Thus electronic and regular mail recruiting touts “all outpatient” in capitals with several exclamation points at the top of the page.

The clear ability to walk away from a job gives me tremendous negotiating strength.

Unlike Sisyphus, who had been condemned to eternally roll a boulder up a hill, only to have it roll down just before it reached the top.

Sleepless doctors losing caring

We deal with death and with pain

The job brings a whole lot of strain

The hours on call

Are the worst of it all

When your sleep goes right down the drain

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Sunday afternoon in the doctors’ lounge the faces show the strain.  We have worked too many hours too intensely.  The energy and the intelligence helps but 48 hours into the weekend call the pulmonolgist, the nephrologist, the hospitalist, the cardiologist and the family practitioners have all done too many admits in the context of not enough restful sleep.

As a med student and a resident I had times on call when I made the mistake of letting myself go all the way to sleep, and then I aroused only with difficulty.  Now amusing stories at the time carried frightful embarrassment.  Most docs had similar experiences, and we learned to doze rather than sleep fully.  I’ve asked other physicians, and about 15% say they can sleep well if they’re on call.  I fall into the other group. 

The muscles in my upper back and the base of my neck grow tender knots and then cramp up. 

With the geographic layout of our town’s two hospitals, walking from car to patient to car, a round trip of hospital-patient-hospital-patient comes to a little over a mile, and with admissions piling up at the average rate of 4 to a shift, physical fatigue adds itself to the list of emotional and intellectual weariness.

Even the brilliant, overachieving docs from other countries who work insane hours without complaining (the way I did as a resident) look tired.  While no one wants to be seen as a whiner, we commiserate and we wonder why this weekend, of all weekends, should be so hard.

My near participation in the pity party ends when my beeper for the other hospital goes off.

I can tell from his use of profanity that the ER specialist has passed his emotional elastic limit.  All his rant about the alcoholic’s manipulative behavior rests solidly on truth, and I recognize in my heart my own impatience with the self-defeating behaviors that brought the person in.  But the doc on the other end of the line goes on for minutes, communicating little about the patient’s medical condition and much about his own anger. 

Across town the patient’s blood alcohol level runs 224.  From experience I know that the interview process will yield little useful information.  Drunk patients want to appear clever and they want to talk and they have problems focusing, but as a physician I just want to collect the information and go home.  I don’t try very hard when it comes to my 140 question Review of Systems, where I ask the patient about every symptom possible.  I break off questioning at the first sarcastic remark, and I don’t try to fight the scrunched-up eyelids to examine the pupils.  My dictation uses the sentence, “could not be obtained because of patient intoxication” a lot.

Overworked docs with inadequate sleep may or may not provide the same quality of care as normally, but they definitely lose out on caring.

Sick young men

 

In came the sickest of blokes,

He drinks, he gambles and smokes

Before he’s wise or he’s sage

He’s at such a young age

And I broke the bad news to his folks.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

The clinical theme of my weekend call has run into the realm of young men with very bad disease.

Any serious illness comes with a certain sense of irony and brings drama to the family context of the patient.  Advanced age lessens drama; a heart attack in an 85-year-old doesn’t carry the same emotional weight as a heart attack in a 35-year-old.

Most of these patients have problems with alcohol and tobacco, and their sum total of illnesses reflect more their life style choices than their heredity; some of the worst problems, though, showed up gratuitously, unannounced and unexpected.

So common do the three problems of diabetes, high blood pressure and high cholesterol run together that when I transfer information from one source to another the number 3 serves as my notehand for those three diagnoses.  That single digit showed up in more than 80% of the work-ups I have done so far this weekend.

But that trifecta in and of itself doesn’t lead a person to hospitalization, but the sequelae from narrowed arteries can bring on heart attacks, stroke, coma, and respiratory failure.

As the day waned and the sky darkened, I sat and talked with a justifiably worried family about a very sick young man.  The relatives didn’t hear the implication of the possibility of a fatal outcome until I stated it explicitly, and I had to endure looks that could kill messengers.

Any family conference involves a lot of questions.  Most interviews start with questions about the illness but progress more and more to issues with emotional content.  Those last parts tax my skills as an interviewee the most, but they bring me a sense of where the person fits in the web of their family; they take a lot out of me emotionally.

An hour later, In the ICU of the hospital on the other side of town, I interviewed and examined a young man who looked twenty years older than his real age.  The things the medical community had warned him about as a teenager had come to pass.  He didn’t wrestle with existential questions, nor did he want to change his lifestyle.  When I finished with the patient, I found no family to explain things to. 

A physically sicker patient in a sociologically healthier context brings a sense of tragedy more fulfilling than that of the ailing loner.   Contrast remains the essence of meaning.

 

One night stand as a nocturnalist; eavesdropping drama and irony

At five I had plenty of rest

I was happy, well-fed and dressed

But my attitude sours

With the wrong kind of hours

Before I got back to my nest.

 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

As a favor to a colleague I agreed to take call the evening of one of my days off.

I enjoyed my leisure before I started to work at 5:00 PM.  I took a friend to an outpatient procedure, did some regulatory tasks and some grocery shopping.  I slept in the afternoon.

I power nap better than anyone I know.  Given 18 minutes, I can go through a complete sleep cycle and awaken feeling rested if not euphoric; given 45 seconds I can recharge my batteries. 

But this time my post-lunch siesta went for hours. 

The beeper started to chirp at 5:03PM.  I handled calls from the inpatient units at two hospitals.

About 7:00PM I got my first ER page for an admission.  I briefly considered bolting a snack before I left, but then I thought about my large lunch and my desire to reduce my waistline.

I admitted the patient in the hospital closest to home, and stopped in the Newborn Nursery on my way downstairs to admit the newest addition to the practice. 

The beeper sounded as I walked in from the garage.  Not really hungry, I took the call and went to the other hospital, feeling chipper and well rested.

I could get used to duties as a nocturnalist (the sort of doc whose main function consists of admitting patients and caring for problems that go wrong in the middle of the night), I thought. 

That hospital grew across a street, and I had to cross a bridge from the old section to the new.  A man stood in the bridge, looking out over the city, talking on his cell phone, the sun setting as the last snow melted.

Confidentiality doesn’t apply to information spoken in a public place by a person not my patient; the words directed to a cell phone registered as I walked past.

“Yeah, his blood counts all messed up now and it looks like he’s got leukemia, and he’s just about had it, he doesn’t want to fight it.”

The drama and irony hit me in four strides of involuntary eavesdropping.  I didn’t look up.

I arrived in the ER still energetic and smiling.  I got as far as introducing myself to the patient, when the beeper started into an unbroken orgy of interruption lasting half an hour. 

I left that ER and got halfway home when another page brought me back.  I had to admit two more patients over the course of the next two hours while another at the other hospital deteriorated.

Midnight found me in the ICU with that patient, talking in hushed tones to the family and shaking my head in unison with the pulmonologist, my nerves jangled, my optimism crushed, and not very much in favor of the idea of being a nocturnalist.

Protecting the patient from medical care

Be careful the diagnosis you make,

Could it be that the patient’s a fake?

If they take too much caring,

And just leave you swearing

That this one sure takes the cake. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

In another century, in another state, I cared for a patient who feigned seizures.  She knew enough neurology to easily fool me and almost enough to fool a very good neurologist.  Before HIPAA, fax machines and the Internet, we did the best we could for the young woman coming in off the highway in the middle of the night, not realizing that her “epileptic” activity came under her complete conscious control.

On her third hospital day, we started getting information in from hospitals and clinics in other states.  I spoke with her parents but she had burnt bridges years before; they stated without rancor that they wanted nothing to do with her. 

The patient was the first I would care for with Munchhausen’s syndrome, a disease where the patient makes the doctors believe illness exists when it doesn’t.

I cared for such a patient today; because of confidentiality I will reveal no details.

Munchhausen patients constitute a no-win situation for the doctor.  If not confronted, they continue the drama, and the illness never resolves.   If confronted, they deny, dissemble, and project, and move on to another facility.

Some but not most work.  Most but not all lead geographically unstable lives.  Occasionally parents use their children to create medical chaos, giving rise to the syndrome of Munchhausen by Proxy.

Some patients have physiologic abnormalities, such as a blood test or an electrocardiogram that never normalizes.  Some have horrendous scars.  A subset of patients uses words and physical findings to obtain narcotics either for their own use or for resale.

They play a dangerous game; I have seen limbs amputated and surgeries performed.  Mostly Munchhausen patients die from medical misadventure.

Once the patient has the diagnosis established, there exists no effective treatment.  At best, a doc hopes to not personally making the patient worse.

Sometimes, the patient seeks nothing other than attention, and I have set up thrice weekly appointments for months to try to protect them from medical care.  But others thrive on manipulating the medical establishment, and find no satisfaction outside of misdirected heroics or anger.

Still, they are human beings, and I wish I had a good treatment for the person I saw I today.

Brief conversation with a widower

Time is the ultimate thief

Our allotment is always too brief.

I learned while in line

This wisdom now mine:

When we leave, we always leave grief.

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

In theory, working part-time, I get two days off per week, except when I have call.

My natural body clock wakes me between 5:00AM and 5:30AM, and I can get a lot done before normal businesses open.  Today, I had to renew my driver’s license.

Most people hate the Driver’s License authorities in their states; I get along with a grudging coexistence.  This time I made sure I arrived early, and I parked in the cold and the rain at 8:20AM, listening to an educational CD on breast cancer.  At 8:27 a man walked up and stood by the door; I switched off the disc and went and stood beside him. 

He looked a decade older than me.  He complained about the office not opening on time right until the key turned in the lock precisely at 8:30.  I stood behind him in line and watched him dealing with the clerk to have his picture taken.  When it came to my turn, I gave up my old license, looked at the bottom lens, and received a ticket with the number 201 on it.  I took my seat beside the retiree at the front.

“I forgot and let my license expire,” he said, and announced he’d be moving to San Diego to live with his son, his only child.

We sat together and didn’t speak.  “I forgot to renew my license when my wife died,” he said.  “We were married for 60 years and I loved her.”

A moment of silence passed while the drama of the ultimate drama irony’s echoes washed through the drudgery of the routine.  I considered contrast as the essence of meaning.

“I bet you miss her,” I said.

He was about to answer when the PA announced his number, 200, for service at counter 8.

I waited and contemplated the enormity of what he’d told me.  I hadn’t told him not to pile too many stressors on at the same time.  Usually I’d tell a patient to wait for a year to move after such an emotional shock.  But he wasn’t my patient, and he hadn’t asked for advice, and I couldn’t say, for sure, that my advice, while qualifying as common sense, had good clinical evidence in large studies.  And it was a public place.

The automated voice on the Public Address called my name to counter 10.  I confirmed my address, height and weight and did the vision test.  My banter with the clerk lacked my usual verve.  I walked out of the office with my temporary license in my wallet, looking around at the mob of people who had gathered in the previous 10 minutes, congratulating myself on arriving early and finishing early and not getting stuck in the line.

As I exited I saw the widower walking slowly to his car, looking lost, and I thought about the meaning of time.

Mission creep: a census grows and genomics comes now comes retail

Does a thousand seem likes it’s cheap?

Beware the assumptions you keep.

Don’t think that it’s strange,

There will always be change,

And ever the mission will creep. 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

Last night I took the handoff for a hospital census of 4, a record low since I started with this clinic.  Even though I arrived for rounds before 7:00AM, that number had grown by 3.  I whizzed through two admissions, three patients with kidney failure, one each with alcohol withdrawal and complex pneumonia, five diabetics, a newborn, and two coronary patients.  (Do the math, you’ll figure out that a patient rarely enters the hospital with one problem.)

The longer a person lives, the richer their life story; and in the course of half an hour I had the treat of listening to a wonderful family history unfolding over the course of three generations.  I left them hope that the specialist would be able to cure the problem. 

But I squandered 15 minutes trying to educate a nurse, who overhearing me speak Spanish, made disparaging remarks about immigrants. 

Still I finished at the one hospital before ten.  At the second hospital, still in the throes of transition from paper charts to a new Electronic Medical Record (EMR) system, I only had to round on the pediatric floor, and I held onto hope of getting to the office early. 

I discovered an EMR quirk: one now needs 9 keystrokes, not 1, to edit a dictation.

I got to the office early, but not nearly as early as I’d hoped.

After half an hour of buffing documentation and messages, I attended what had been billed as a provider meeting.

The man who brought the lunch didn’t pitch a drug but a lab test.  Using material on a cotton swab from the inside of the mouth, for a mere thousand dollars, his company can provide us with genomic information about how fast or slow a person might metabolize a range of medications. 

For example, a single standard 30mg dose of codeine provides good pain relief for 80% of the population.   But 20% of population lacks the enzyme to convert codeine to morphine; for those people, codeine might suppress a cough but won’t relieve pain.  The super enzyme found in 1 in 3 Somalis converts 100% of the codeine to morphine on the first pass through the liver, enough to kill half of those who try it.    

Our clinic prescribes almost no codeine.  For whom will the test bring a thousand dollars with of benefit when it comes to choosing an antidepressant, antipsychotic, or ADHD medication?  We requested more information.

I didn’t ask the larger question: how long will it be till an entire genomic sequencing becomes available for that price? 

Mission creep remains a permanent fixture on the constantly shifting medical landscape.  Whether a doctor deals with a growing census, or a company sells technologic improvements, we all know that the world, at the end of the day, will not be the world we had at the beginning.

 

 

Is mole (moe lay) chili?

Where we live the country is hilly

And people might think that it’s silly

With no burger nor bean

Whether it’s red or it’s green

To call my recipe chili.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I made my second foray into competitive cooking today at the clinic’s annual chili cook-off.

My first experience came while still working at the Clinic Formerly Known As Mine.   I had a dynamite recipe, inherited from my mother; it brings consistent accolades when I serve it to guests.  But in accepting corporate sponsorship, I accepted the mandate to make the product heart healthy.  Perhaps my sponsors didn’t mean vegan.  I definitely do not qualify as a vegan.  But I decided to make a vegan chili.

I considered the basic recipe, and after a couple of false starts, decided on ground roasted pumpkin seeds as the substrate.  Once a week over a twelve week summer, I produced another batch, each time fine tuning the mixture of spices.

Simple arithmetic scales a recipe easily; if I put 12 cloves of garlic into a recipe that produces 4 quarts, I need to use 120 cloves of garlic if the rules say I need to produce 10 gallons.  I did the math, I prepped the ingredients, and on the day of competition I arrived early.  With the help of a friend and my wife, we cooked for four hours.  The chili came out absolutely delicious.

The contest awarded a total of 30 prizes to a total of 27 competitors. I won none.  Of the 10 gallons of chili I made, we brought home 9.

In the end, I decided that entering a vegan chili in an Iowa chili cook-off made as much sense as bringing a knife to a gun fight.  Even if every bunch of hungry firemen and ER staff we gave the leftovers to loved it.

The tastes of cocoa and tomato disappear and a distinctive savor that the Mexicans call mole (pronounced moe lay), replaces them both.  Finding the correct balance is very difficult.  My mother got a recipe out of the newspaper, and in an uncharacteristic move, followed it to the letter, nailing a culinary conundrum the first time out.

I took the recipe to college and refined it.  I adapted it from chicken to hamburger, and eventually to deer, elk, and aoudad.  I decided that the meat didn’t matter with a sauce that good.

Which brings up the question:  What is chili?  Growing up it meant browned ground beef, canned tomato, and beans.  When we lived in New Mexico, it usually included meat, rarely tomatoes, never beans, but always chiles, whether green or red. 

This time I used dark meat of turkey as the base; I would rate the result as exquisite.

I wanted to win the contest but I didn’t want the prize, a gift certificate to a faux Mexican food chain.  Bethany and I know we don’t like their food because we ate what drug reps gave us. 

Five cooks entered the contest.  I didn’t place in the top three.  I suspect I came in last.

I came away a trifle disappointed, but I really liked having one of my favorite dishes as a hot lunch. 

Enjoying your own cooking ranks as more important than a prize in a chili cook-off.

Maybe I would have won if I had used beef instead of turkey.  Maybe I would have won if my entry had less heat. 

Maybe mole isn’t really chili.

Next year I might try doing a Pueblo Indian-style beef red chile, something that I’ll work on this summer, with chunked chuck and cascabel chiles.

If I win, I hope I like the prize.

Chicken Mole

3 pound chicken, cut up

Olive or corn oil

1 large green pepper, chopped coarse

1 large onion, chopped medium

28 oz can crushed tomatoes

12 ounce can tomato paste

7 rounded teaspoons cocoa

2 ½ tablespoons ground cumin

Ground chile, chile molido puro, powdered chile, jalapenos, or crushed red pepper; the inherent heat will dictate the amount.  I use 2 ½ tablespoons of a medium hot ground chile.

Garlic to taste

Water as needed.

In a heavy pot, brown the chicken and remove.  Sautee the pepper and onion.  Add tomato paste and crushed tomatoes, thin with ½ cup water, and add cocoa.  (The balance can be so close that scavenging the fugitive bits of tomato paste left in the can make the difference between success and failure; the result should taste neither of tomato nor cocoa).  Press in the garlic.  Add the cumin and the chile, stir in ½ cup water, add the chicken.  Bake covered at 350 degrees for 90 minutes.  Serve with soft corn tortillas and/or rice.  Serves six.

Bits and pieces, clinical and otherwise

After shaving off all the head’s hair,

My patient said, “What is this there?

For my scalp is so sore

I can’t touch anymore

And the smallest exertion’s a chore.”

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I met a person with the last name of Jeffords. 

“Any relation to Tom Jeffords?” I asked.

Yes, came the reply. 

Tom Jeffords carried US mail in Arizona Territory back when the Apaches didn’t hesitate to expend ammunition when showing disapproval of the new invaders.  After the Chiricahua killed a couple of his carriers, he rode his horse into Geronimo’s camp and demanded the depredations cease.  Geronimo, impressed at the personal courage and straightforward approach, agreed, and the mail went through unmolested.  The two men became fast friends.  When his Apaches went to their new reservation, Geronimo requested Jeffords as his agent, Jeffords accepted, and, to the best of my knowledge, became the only Indian Agent to remain uncorrupted by his position.

I knew the story in far greater detail than the Jeffords I talked to.  Tom Jeffords still holds my admiration for personal courage and integrity; we agreed that such characteristics come rarely and we wished we could find men like Tom Jeffords in prominent positions in our government.

++++

Today I took care of a patient who noticed tenderness in the scalp after shaving (in the 21^st century, make no assumptions about age or gender of the patient).   This unusual complaint puzzled me, but remembering the adage, “When all else fails, examine the patient,” I reached out to the touch the indicated area and found it warm and swollen but not red.  I looked at one side then the other, and realized that the temporal artery stood out on the right.

Temporal arteritis remains a mysterious disease; for unknown reasons the arteries throughout the body become inflamed.  As a result those afflicted feel run down, have morning stiffness, and lose strength in their shoulders and hips.  As I queried my way through the list of symptoms the patient became more and more puzzled that I would even ask such questions (the patient also gave me permission to include a great deal more information than I have).  Front line docs don’t see a lot of it, maybe a case every couple of years, and we usually refer to a rheumatologist if available.  Head-shaving, increasingly popular through many segments of the population, occurred rarely during my training years; it made the physical finding visible which before were only tactile.

+++

I started early without trying this morning at 6:15AM, and finished my share of hospital rounds at 8:15.  While I could have conceivably taken the morning off, I used the windfall hours to catch up on hospital documentation.  At 10:30 I had made great progress and went over to the office and worked on my paperwork backlog till patients started at 1:00PM.  For some unknown reason one hospital began sending me lab summaries from patients hospitalized as far back as last July. 

I can pull up the patient’s electronic chart and see if the information has already been downloaded, but given the peculiarities of our system, it goes faster to sift through the data as if I’d never seen it.  Not to say it goes fast.  It doesn’t. 

 

The doctor takes the wrong end of the scalpel

In the head there’s this thing called a brain.

Where we feel our pride and our pain

But when the cutting is done

Are narcotics just fun?

Or the source of some ill-gotten gain?

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Recovering from surgery cuts into the desire to write, but I’m doing better now.

Even doctors must have doctors; the internal dialogue that leads us to minimize contact with our own profession has gradually led us to healthier life styles.  Few doctors smoke in the 21^st century; most of us exercise regularly.  While no doctor should prescribe for him or herself, neither should any patient completely abrogate self-advocacy nor decision-making. 

I won’t dwell on the circumstances that led me to a repeat surgery; denial worked for a long time but eventually failed.  Thus on Valentine’s Day I sat in our local specialized surgical center, hungry and thirsty waiting for anesthesia.

The procedure started on time, but went long, only because of the nature of the problem.

A lightweight when it comes to most medications, I dozed off and on for the rest of the day.  When it came time to leave, I adamantly refused a prescription for a popular narcotic.  The exchange with the nurse went several rounds and finished with her tearing the slip to bits and putting it in a small plastic envelope designated for that purpose.

All narcotics slow the gut and suppress the cough reflex.  I feared constipation (after a major abdominal procedure) and pneumonia more than I feared pain.   Nor would my marginal kidney function permit me the usual pain relief of the NSAIDs (a drug class that includes Ibuprofen, Alleve, Toradol, diclofenac, and 28 others).

Which left humble acetaminophen, also known as Tylenol.

If we assign post-operative pain a range of 1 to 10, we know that the much-abused oral opiates like Percodan and Norco can bring the pain down by 2.7 points in the same study where an inactive pill will bring it down by 2 points and Tylenol by 2.1 points.

(Interestingly, propoxyphene, the active ingredient in Darvon, now removed from the market, would decrease it by 1.7, which means that despite bringing euphoria, a drug could aggravate acute pain; a phenomenon we see with marijuana and chronic pain.)

I have spent most of the last 5 days asleep, but today I’m coming around.  My appetite and my sense of humor have palpably improved through the day.  I still fear coughing but I do it anyway. 

I didn’t actually need the narcotics.

When I talk to my non-drug abusing patients after a surgery, most of them didn’t, either.