A breakfast meeting with a new colleague

December 13, 2014

A respite that’s every so fleeting

From the diseases we find ourselves treating

I sat down to talk

With a colleague, a doc

An informal at-breakfast meeting

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years.  I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.

During my time in Barrow, Alaska, the doctors met every morning from 8:00AM to 9:00AM.  We reviewed admissions, evacuations, problem patients, and interesting cases.  The agenda rotated around the table, everyone had a chance to talk and everyone had something to say.  Each time I left the table a better doctor than when I sat down.

When I returned home after my walkabout year, I fell in with a couple of colleagues who had also worked in Barrow.  We breakfasted together once or twice a month, and the informal meeting always made us better doctors.  Neither of those docs works in town now.

I breakfasted with a new colleague, Board certified in both Psychiatry and Family Practice.  I got to tell her about the Old Days, when med schools actively excluded women, doctors could hit patients but only when they deserved it, laparoscopic surgery existed exclusively as an idea in my head, and the diagnosing primary care doctor earned a lot of money as the surgical assistant.

I told her about the funeral I’d been to earlier in the week (see the previous post), and the amazing surgeon I’d had the privilege to know and work with.

Over semi-scrambled eggs with mushrooms, onions, and smoked turkey, I laughed with her at her vivid description of her embattled clinical situation.  As with most who work in community health and/or with the mentally ill, she faces an impossible situation of inadequate resources and challenging patients.  She compared it to a battlefield front-line aid station equipped only with eye-patches.

We discussed obstetrics, how much we both enjoyed it and how much I enjoyed stopping.  We agreed that the feeling in the room immediately after a birth carries an evanescent sense of perfection not found elsewhere in this life.

I got to talk about how I learned how not to interrupt the flow of feminine energy in the process of a delivery.  I have found this concept nebulous and difficult to teach and embarrassing to talk about in the company of the coldly analytic.  Nonetheless when I figured it out the deliveries went better.

But I didn’t sugarcoat the problems that I had at my last delivery (see the post from April 2010, http://walkaboutdoc.wordpress.com/2010/02/24/my-cancer-removed-reflections-on-being-a-male-in-ob-a-frightening-delivery/.

We discussed beepers and the psychiatric community and why the dynamics roll the way they do.  And we talked about writing.

She might start blogging.

A Surgeon’s Funeral

December 8, 2014

He was a surgeon to know and admire
To snatch the fat from out of the fire
He came to the ill
With grace and with skill
A light when things were most dire.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.
Medicine has always been a team sport.
When I first came into private practice from 5 years in the Indian Health Service, I had to get to know the specialists. In less than a year, I established a reputation as a sharp diagnostician. In retrospect, though, it seemed to me that very complex clinical situations presented themselves to me in such an obvious fashion that I could make an outstanding diagnosis and look like a hero.
For example, I diagnosed 8 women with ectopic pregnancy in 6 months. The principle has long stood that any woman of childbearing potential with abdominal pain has ectopic pregnancy until proven otherwise; I embraced that piece of wisdom and saved lives. But each one presented on a different gynecologist’s call night, so that in short order my consultants came to trust my judgment.
On one particular night, I called a surgeon and said (the patient’s identifying data may or may not be precise) “I got a 14-year-old white male with increasing abdominal pain times three days, originally vague and near the umbilicus (navel) now localized to the right lower quadrant, worse with jarring, accompanied by loss of appetite. No major medical problems in the past. He has decreased bowel sounds, a little guarding, tender at McBurney’s point, rebound, referred pain to the right lower quadrant, and positive heel, psoas and bunny hop signs. He did not enjoy his lunch. Blood and urine are normal. I think he has appendicitis, and I’d appreciate it if you’d see him.”
In those days the primary care doc scrubbed in with the surgeon as assistant. I watched in awe as he flowed through the surgery in less than 5 minutes; poetry in motion and economy of movement really don’t do justice to the beauty of how his hands worked. Before the advent of laparoscopic surgery, he could do an appendectomy with an incision less than an inch long.
The guy was slick.
We did a lot of those cases together, and as the critical first months in a new medical community passed, I built such trust with my consultants that I could say, “Hey, Don, you wanna go fishin?”
We worked well together.
As medicine progressed, we both aged. He retired a number of years ago.
He died last week, and I went to the funeral today.
I saw a lot of the docs I knew from those days; a urologist who had left town last century, a half-dozen Family Practice docs, three surgeons who had worked with Don back in the day, two pathologists, a radiologist; some retired and some still working.
The service had a light mood; Don had a full life and enjoyed tremendous respect.
I held the door for the widow after the internment. I hadn’t known her to speak of but she looked at me and stopped and addressed me by name. “Don thought the world of you,” she said, “He said you were one of the sharpest doctors in town. He admired you.”
I hadn’t known that. It meant a lot to me.
“I admired him,” I said.

Work hunger

November 30, 2014

With the questions they’re asking of me
You could say that I’m working for free.
I really don’t mind.
I think that it’s fine
I darn sure don’t want the fee.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now back from a road trip to visit, and take in Continuing Medical Education, I’m helping to fill in at a clinic not far from home.

In a social gathering, a physician can be sure that people will approach with personal medical questions, unless doctors comprise the gathering, and even then sometimes the doctors will reality test with other doctors.

One doc I know got fed up and said to the person at hand, “Just go back to the bedroom and take off all your clothes, and I’ll be there in a minute to examine you. After all, a medical visit includes an examination.”

Another, while in med school, told her less-than-sober relative who had harassed her with sexual innuendo thinly disguised with a medical question to take down his pants, and let’s have a look at the part involved. Which effectively shut him up.

And on one occasion, I confess that I snapped, “I’ve just worked 14 hours, my mother died 8 days ago, and if you want advice, make an appointment and expect to pay just like anyone else. You’re not giving away your refrigerators for free.” (I didn’t refer to refrigerators; but even in public I’ll protect confidentiality. That only happened once. And while I’m not proud of my response, I can see that the comment found me in the midst of the grieving process.

Mostly, we get used to it.

Over the holiday, people with skin, weight, headache, chest, emotional, and sleep problems came to me in the context of prolonged sedentary feasting.

And I didn’t object, in fact, I welcomed it.

I miss my work. My current situation finds me with an unsatisfying number of patient contact hours. I got to give sound advice, especially what the person should say to their doctor, in an unhurried fashion. I didn’t have to worry about the tyranny of documentation or billing. Nor did I write a prescription.

And I got the chance to delve into the patient’s situation: what did the illness mean to him/her? Friends and family contributed to the history, and I got a much better picture of the whole situation. So I could say, for example, make sure you tell your doc your whole family history. Or, metoprolol is a better, cheaper beta blocker than atenolol or labetalol.

And later on, I could go on the internet and access Sermo.com, a website exclusively for licensed physicians. A doctor can post details of a puzzling case, and other physicians can comment. They brought me a new perspective: testing might show you the patient’s allergies, but the allergies may or may not cause the problem.

Dr. Germaphobe at Thanksgiving

November 26, 2014

‘Tis the season to bring on the mood,
Our calorie count to delude
What makes us so sick
Not sleeping’s the trick
And the crowding, the booze, and the food.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now back from a road trip to visit, and take in Continuing Medical Education, I’m helping to fill in at a clinic not far from home.

At this time in November, most Americans start their annual feasting season, though a few started 3 weeks ago on Halloween.

The average American gains 5 pounds between Thanksgiving and New Years Day.

We also travel to new locations with new microbes. We crowd, making microbe transmission easier. We disrupt our sleep patterns by our travel plans and our socializing. Lots of us consume much more alcohol than we’re used to. While we weaken our immune systems and confront them with strange germs, we gorge. And then we wonder why we get sick.
I get great welcome at Thanksgiving for my knife sharpening abilities and for my turkey carving skills. My ability to bring a shaving edge to most any non-serrated cutting instrument comes from years of hunting. My medical training has nothing to do with slicing white meat.
But my bacteriological knowledge, tuned to a fine paranoia by the CDC’s applied Epidemiology Course’s Food Borne Illness section, has not met with the same enthusiasm. I have even earned the nickname Dr. Germaphobe for my recommendations: keep the hot food hot, the cold food cold, and only reheat once.
People will cheerfully ask me about rashes. They express sincere gratitude when I put a razor edge on their knifes using nothing more sophisticated than the bottom of a coffee mug. But I can tell they politely suppress the eye-roll when I talk about food poisoning and room temperature.
I have stopped telling the story about how the Mars Lander program used chicken soup as a medium to detect extra-terrestrial life. I’ve inflicted it upon my family too many times.
They still invite me to make the gravy.

November 23, 2014

It’s now the start of the season
With the coughin’ and sore throat and sneezin’
And then there’s the nose
From whence mucus flows
And the smokin’ brings on the wheezin’

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now back from a road trip to visit, and take in Continuing Medical Education, I’m helping to fill in at a clinic not far from home.

I drove east on a Friday morning, into the rising sun, listening to a Continuing Medical Education program and my GPS, Samantha, to an outlying rural clinic.
The town qualifies as small. People don’t lock their houses or cars; local funds built the library, and nobody can claim the traffic made them late. I parked in the alley behind the clinic.
A short tenure in a health facility doesn’t justify the expense and pain of setting up an Electronic Medical Record (EMR) system account when the doc just fills in for a few weeks. Thus I got away with dictating my records as I’d done for the first couple of decades of my career. I passed 15 minutes determining that neither of the ancient micro-cassette recorders could be rendered functional. And then the nurse told me my first patient awaited.
Seventy-five percent of the patients I saw had respiratory problems. I spent a lot of time explaining why I wouldn’t prescribe antibiotics and felt relief when a patient with sinusitis (who had been better and then got worse) needed amoxicillin. The pattern for almost everyone started with high fever, resolving within hours, followed by a severe sore throat lasting less than a day, and a main complaint when they arrived of cough and stuffy nose. I quoted Star Trek twice by doing my best Bones imitation of “Why, Jim, I can no more do that than I can cure the common cold.”
On three occasions, I asked the patient, “On a scale of 1 to 10, how ready are you to quit smoking, where 1 means you want to die with smoke in your lungs, and 10 means you quit an hour ago?” As always, I had to coax a numeric response, and then I asked, “Why not 2? Tell me three good things about smoking.” I listened and repeated, but I didn’t belittle or make fun of the response. After all, everyone knows the dangers of smoking, everyone has been told to quit, and shaming hasn’t worked. To capitalize on their ambivalence, I sought only to make them think about their habit.
For many, the worst symptom came down to a stuffed-up nose. Ipatroprium effectively relieves that problem, but I prescribed so much that the town’s pharmacy called before 11:00AM to say that had run out of it and couldn’t I please prescribe something else.
After being away from clinical work for weeks, I reveled in the tasks, the patient contact and the conversation. I got to talk with farmers and cattlemen. I established rapport with pediatric patients by playing with my yoyo. I successfully examined the ears of an 8 month old without using force.
I got to eat lunch, then I used a phone-in dictation line.
And I finished early.

November 22, 2014

On line, I went shopping for socks,
The prices are horrors and shocks
From too many years
Of avoiding arrears
And counting the ticks and the tocks.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now I’m back from a road trip where I visited family and friends and attended Continuing Medical Education.
For decades I spent most of my time working. I didn’t have disposable hours in which to spend the money that I acquired. Thus I regarded the holiday shopping season with dread. Throngs of people spending money that they couldn’t afford to buy presents for people who didn’t want them made getting into and out of a store too much of a time commitment. So I wouldn’t go shopping between Thanksgiving and January 1 unless I had to buy food. And, in general, I didn’t have the time to go shopping anyway, so that my spending habits didn’t change much.
Actually, in medical school and residency I got really good at living with minimal expenditure of money. I had little cash in those days and even less time to spend it. In the subsequent years my income grew but my wife and I didn’t change our buying habits.
Since I redirected my career path in 2010, I have more free time. Though the years have passed and prices have risen, my sense of how much something should cost remains stuck in the 70’s. Back then, $5 could buy a pair of Levi’s, $.50 a gallon of gas, $.32 a pound of chicken. A dollar would get you a pound of chuck steak, a pair of Interwoven socks, or a hundred rounds of .22 ammo. While paying the going price for footwear, clothing, and other goods horrifies me, I grit my teeth, tell myself to let go and help the economy, and hand my credit card to the teller.
I do that more often on those days when I don’t work. And I can do it so easily with my computer.
On a recent day at home I bought gifts for the people I stayed with, a battery for my wife’s computer, socks, and some chocolates. And then I went out and dropped more on sushi lunch than I used to spend for a week’s groceries. I know I need to get used to the higher prices of goods, and to learn generosity towards myself.
I’m still aghast at what I have to pay for a pair of socks, even if they last a decade.

Road Trip 8: Fantasy bare-bones formulary

November 18, 2014

For our tools, the meds are the core
I used to use way less than a score
Is a need demanded
Drugs that were branded?
Saying “no” is really a chore.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. I just returned from a road trip, to visit family and friends and attend a Continuing Medical Education conference.

After the Continuing Medical Education ended, two daughters and one son-in-law accompanied me to sushi lunch, followed, naturally, by dessert.

The ice cream parlor sat in a building that had previously housed a drug store. Closed in 1979, the interior stayed intact until the building sold to new owners who rehabilitated it and decorated it with stuff that had remained from the pharmacy years.

We observed the lack of variety in the drugs that graced the shelves, and soon the two physicians (my daughter and I) dominated the conversation with the question: If you were Minister of Health for an impoverished, small island nation, what drugs would you have on your formulary if you could only have twelve?

We started with pain relief, my younger colleague wanted ibuprofen and acetaminophen (Motrin and Tylenol); and for high blood pressure lisinopril and metoprolol. I agreed with acetaminophen and lisinopril, allowed as how I could live with metoprolol but would prefer carvedilol (in the same class of high blood pressure meds, but also useful in heart failure), and didn’t want ibuprofen at all. “Too many side effects,” I said, “Ulcers and kidney damage and such.”

Diabetes, I declared, should be met with metformin; she would prefer a long-acting insulin. And I could see her point. A long-acting insulin would at least keep the Type I diabetics alive.

I kept looking over her shoulder at the few shelves lined with medication bottles. I remembered, during residency, checking out the 1979 Physician’s Desk Reference and comparing it to the 1980 edition and thinking how small the earlier version looked. With more than 4,000 pages verging on folio size, the current edition dwarfs both put together.

What about antidepressants? We agreed on citalopram. Antipsychotics? Haloperidol (brand name Haldol). Sleeping pills? I voted for trazodone as a triple function drug, useful for depression, chronic pain and sleep.

For antibiotics, we agreed that if we only used amoxicillin sparingly, resistance to it would fade. I wanted another one in addition, such as doxycycline or azithromycin. And I shook my head; doxycycline has gone from $.04 per pill to $3.50 per pill. I asked, What about mupirocin (a topical antibiotic) but the question went unanswered.

If we hadn’t forgotten about thyroid disease, I would have suggested levothyroxine. But we finished our ice cream and went out into the afternoon sunshine. “You know,” I said to my daughter, “In the last three years, working at a Community Health Center, I know there are a lot of really neat new drugs out there, but I don’t prescribe many. Do you write for much in the way of branded meds?”

“No,” she replied, “About the only drug that’s on patent that I prescribe is Plavix (which helps prevent blood clots).” She recounted a conversation with a salesman representing Oxycontin; neither of us prescribe it at all. The rep had asserted the new reformulation made it less addictive. We laughed. A drug like that doesn’t need a rep.

During residency, I clearly remember the program director teaching us that most doctors use fewer than 20 drugs. Pick one from each class, he said, and get familiar with their side effects and their interactions. But he taught us those things before the Information Age and the Internet.

We got in the car. “What about asthma?” I asked.

“We’d have to have albuterol,” she said.

“And prednisone?”

“Yeah, I guess we’d have to have prednisone,” she said.

I suggested single 20 mg tablets scored with three lines on one side and four on the other.

Road Trip 7: three days of Continuing Medical Education in Pittsburg

November 9, 2014

For pills the pain to abate,
Please limit the number to 8
Is there to be an excuse
For narcotics abuse?
And tobacco opens the gate

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Right now I’m on a road trip, visiting family and friends and attending some Continuing Medical Education.

Every Family Practitioner, in order to claim the title Board Certified, has to take 50 hours of Continuing Medical Education (CME) yearly. Today I finished up a three day conference in Pittsburgh, Pennsylvania. I picked this venue so as to attend with my daughter Jesse, and her husband, Winfred.

The thrill of having my daughter and son-in-law as colleagues in this experience permeated the weekend.

The first day, Friday, I spent improving my well child checks. I found little new information, but that doesn’t mean I’ll pass the online test the first time. One of the presenters deserved the designation gifted teacher, a dynamic speaker who convinced me at every turn that I could master the material.

Yesterday a former DEA agent brought in the bad news about America’s epidemic of narcotic abuse, but more importantly told us what we could do about it. I found most interesting the fact that for new, severe pain, such as burn or broken bone, the average number of pain pills taken comes to 8; the others in the prescription hang around the medicine cabinet till some teenager pops them to see what happens. The presenter made the very good point that the doctor needs to make sure the drug prescribed goes into the right patient, whether it’s an opiate or an antibiotic.

Immediately after that I learned about the complicated new process to keep my board certification current. I still need 50 hours of CME a year, but I also need to complete three other projects every three years. An unnecessarily complicated process, the lecture took 45 minutes. I’ll be calling the helpline later this week.

And new information kept rolling in.

Human Herpes Virus 6 (you’ve heard of 1 and 2) causes pityriasis rosea, also known as the Christmas Tree rash. Acyclovir shortens duration of symptoms by 3 weeks. Three of us turned to each other in amazement; none of us had known that. Never assume that nothing changes, the lecturer said; the smartphone in this case saved the patient.

Sometimes a growing adolescent’s hip loses the growth plate, we call the condition slipped capital femoral epiphysis. To diagnose on physical exam, lay the patient supine, and passively flex the hip; if it has to rotate outwards, the patient will probably need surgery.

Road Trip 5: vegan lunch and free advice

November 5, 2014

Sometimes over coffee or tea
People want my advice, just for free
If they ignore what I say
I ask them to pay
But I’ve never collected a fee.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I used vacation time to do two short assignments in Petersburg, Alaska. Currently on a road trip, I left the Community Health Center last month because of a troubled Electronic Medical Record (EMR) system.
Wherever I go, people, on finding out my occupation, will ask me for free medical advice. I tell them if they take the advice, it’s free, but if they ignore it, they’ll have to send me payment.
Lunch today was no exception. I won’t go into the details of the case, even though the patient gave the information in public in front of an audience. The gastrointestinal symptoms had persisted for decades.
I always start with a good history, so as we dug into our gluten-free and vegan fare, I asked the basics: when did it start? Where do you feel it? How bad is it? What happens? What is the character of the pain/smell/discharge/problem? If it comes and goes, how long does it last and how often does it happen? What makes it better? What makes it worse? What have you tried that helped? What have you tried that didn’t help?
The luncheon café setting precluded doing any sort of physical exam beyond that inherent in conversation.
I never prescribe medication in such situations, though sometimes I advise the patient check with their doc to discuss lab or drugs.
Mostly I do non-pharmacologic therapy.
I usually start with ABCD: always blame the cotton-pickin’ drug, thus stop nicotine, caffeine, alcohol and any recreational pharmaceuticals. Then I start into the med list.
Most diseases fall into a spectrum of severity, and proper attention to sleep, diet and exercise can shift almost any medical problem into the less severe range. So sections of advice overlap, because nicotine, caffeine, alcohol and recreational chemicals murder sleep. Some fun pharmaceuticals (such as alcohol and marijuana) bring on sleep but suppress the most restful phases, delta and REM. Thus leading to chronic fatigue and loss of emotional resilience, and thus they make any disease state worse. In particular, I said, if the mind stays out of balance, so will the intestine, as all neurotransmitters (chemicals that carry messages in the brain) have receptors in the gut.
I also recommended a week’s trial of the Prune Water Protocol: put a prune in a glass of water and leave it by the side of the sink till you go to bed, then drink the water, eat the prune, and brush your teeth. Repeat twice daily. A lot of chronic digestive problems come down to chronic constipation (usually from incomplete emptying), and I haven’t met a case of non-malignant constipation that resisted the Prune Water Protocol.
The patient may or may not follow my advice, but certainly won’t pay me.

Road trip 4: with my brother in Woodstock

November 3, 2014

If addiction is the sum of all fears,
Do we wait till it all comes to tears?
Or is our prediction
Of a bad prediliction
Towards the whiskeys, the wines, and the beers?

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I used vacation time to do two short assignments in Petersburg, Alaska. Currently on a road trip, I left the Community Health Center last month because of a troubled Electronic Medical Record (EMR) system.
I dropped my sister, niece, wife, and stepmother at the Long Island Railroad station, put my brother’s address into Samantha, my GPS, and set off for upstate New York.
My brother, an artist, recently moved into a very nice house near Woodstock. As the wind picked up and the temperature dropped, we walked around his acres. I gave him my amateur pomologist’s opinion of his aging apple trees. I looked at the standing but dead timber around the property and did some onsite surface archaeology. His girlfriend joined in the discussion of planting fruit trees.
We talked about our careers over sushi in town. Freelancing for an artist bears similarities to locum tenens for a doctor, especially in terms of contract negotiation. We agreed that inability to at least appear to be willing to walk away from a deal ruins a negotiating position. I detailed my recent untoward experience with a recruiter low on professionalism.
My brother recently studied hand anatomy. I brought to his attention how much all seven siblings’ hands resemble each other.
Later, at his house, we sipped at small quantities of very expensive bourbon, and brought up the subject of addictive disorders in our own lives and in our family.
The key to recognition of an addiction is continuance of a behavior despite adverse consequences, especially missing social commitments.
I put forth my analysis of taking call as an addiction for doctors. He pointed out, correctly, that insight rarely creeps into addicts’ lives. Then we tried to figure out which behaviors qualify as addictions.
I talked about a friend who works as an alcoholic; his business relies on selling wine and spirits. He starts drinking when he gets to work and stops when he gets home; it doesn’t interfere with his work, but, still, that doesn’t keep him from the diagnosis. And it might make bring new depth to the term workaholic.
Our conversation turned to sociopaths and the problems society has from those who enjoy other people’s pain. Probably those people tend to certain professions, including police, corrections, military, and, regretfully, medicine.
Then I started telling jokes. All seven siblings share a quirky, off-the-wall sense of humor; we bring quick, easy laughs to all conversations. My ability to remember and effectively tell jokes remains as rare in our family as it does in general.


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