And after one day’s unemployment…

October 26, 2014

I drove a half-hour away
I had a great clinical day
Oh, what a tonic,
I ignored the electronic
And dictated what I had to say.

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 did two short assignments in Petersburg, Alaska. On Sept 2, I turned in my 30 days’ notice.

On Monday this week I drove to Anthon, Iowa for a day of locum tenens work.

Over the weekend, in different social situations, two people approached me for medical advice, mostly having to do with medical care by other docs. For one I later wrote an email to the family, using physical examination buzzwords, expressing my concerns, and, hopefully, getting the patient into a neurologist in a timely fashion.

I made a phone call for the other patient, leaving a voice mail for their other doctor that I wasn’t officially on the case, I had observed certain things, and if the patient took Zoloft and Prozac, perhaps lorazepam could be discontinued?

Monday I left home early for Anthon, a quiet, prosperous but very small farm town. I’ll be working here from time to time for the next couple of months, in the complicated aftermath of a rural doctor’s personal tragedy.

The patient demographics stand in stark contrast to the Community Health Center. Most patients have insurance or jobs or are retired. No one has an accent. I did not see a single patient with major psychiatric illness all day.

Alcoholism, regretfully, stalks the clinical landscape as ruthlessly as everywhere. I applied my recently acquired Motivational Interviewing skills to the situation, and got at least a couple of people to think hard about their lifestyles. At one point, having gotten the initial three minutes of history, I asked very specific questions about the family history and got accused of being a psychic.

The ravages of past tobacco abuse permeated the day. I got the chance to interview one patient about experiences during World War II, and what it was like to grow up on a farm in the 20’s.

I said, as I have said before, “Weight loss in 21st century Iowa is NOT NORMAL and whatever else is wrong with you we have to investigate,”

I prescribed trazodone for depression, chronic pain, insomnia, and appetite loss, noting that the young doctor knows 20 drugs that will treat a disease but the old doctor knows one drug that will treat 20 diseases.

For the second time since I left the Community Health Center, the possibility of Parkinson’s came up.

I ate a leisurely lunch with the staff in the clinic’s tiny lunch room. We finished at 3:15, and I drove back to Sioux City.

I passed the whole day without getting behind in my documentation. The management spared me the learning curve of an apparently very bad Electronic Medical Record system, and I got to dictate my notes. Like in the old days when we had paper charts.

Talking to recruiters.

October 26, 2014

For the what, the when and the where
For a job with inpatient care
I could compromise
On the salary size
But not things that I wouldn’t dare.

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. I left the Community Health Center this month because of a troubled Electronic Medical Record (EMR) system.
I’m talking to more recruiters these days. When I tell them I’ve recently left a position I can hear an optimistic catch in their voices. Two days ago, I said, “I imagine you have to deal with a lot of rejection in your job.” Yes, she admitted, she does.
My ideal job, I tell the locums agencies, runs something like this (translation to follow): Hospitalist, 7 on/7 off, 12 hour AM shift, ER codes, intensivists on staff, no procedures, in Alaska.
Translation with explanation:
Hospitalists take care of patients sick enough to need hospital care. The hospitalist movement goes back no more than 10 years in this country. The US remains the only industrialized nation where outpatient doctors care for patients in the hospital. During residency in the 80’s, the older docs would point out that hospital work brought in money with no overhead aside from billing; but 20 years ago we started to look at the time we spent getting to and from the patient. A decade ago we looked hard at the inefficiency of drive time. Yet when, for a multitude of reasons, I took over my practice’s inpatient duties at one hospital, I found economies of movement which increased productivity with no shrinkage of patient contact time. And when I came to the Community Health Center, my contract specified I would work half-time as a hospitalist. That operation dropped adult inpatient work last December because the midnight-to-morning workload became unmanageable.
7 on/7 off refers to a work schedule of seven consecutive work days followed by one week of continuous rest. While an 84 hour work week sounds brutal, it affords the opportunity of going home in between stints.
12 hour AM shift is not really AM, but in the business it means 12 daylight hours, as opposed to the night-time hours. I really have paid my dues at this point and put in more than my share of sleepless nights. With the hospitalist movement has come the sub-genre of nocturnalist, so new that the position is sometimes called nocturnist; by whatever name, someone gets paid to take calls in the hospital all night.
ER codes means that the ER physician responds when a patient’s heart stops beating, to attempt resuscitation. Some docs, not me, enjoy the action, and compare it to “going to the Super Bowl”.
Intensivists on staff: With subspecialization, we now have doctors that do nothing but care for ICU patients. Sick enough to need an ICU means sick enough to needs a lot of doctor time. Trying to combine those patients with the less sick frequently means irreconcilable time conflicts.
No procedures recognizes that my skills at intubation, central line placement, and arterial line placement faded before the turn of the century.
In Alaska: self-explanatory.
Of course I expect to compromise on at least one of those parameters. I don’t demand my first choice, and so far I’ve said yes to three positions that haven’t happened. Yet I’ve learned how to have a good time anyway.

Caribou hunting on the other side of the date line

October 21, 2014

On an island where the bald eagles nest
So distant that East turns to West
For days, just a few,
I chased caribou
And had a well-deserved rest.

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. I left the Community Health Center this month because of a troubled Electronic Medical Record (EMR) system.
I went caribou hunting on Adak Island, the southernmost of the Aleutians, and both the most western and most eastern permanently inhabited place in the US.
Russian enslavement of the Native Aleuts in the 1700’s and the subsequent famine depopulated Adak. When, during WWII, the Japanese invaded Attu and Kiska, at the eastern end of the Aleutians, Adak remained uninhabited. The population peaked at 100,000 for the campaign against the Japanese. During the Cold War, the Navy stationed 6,000 on Adak, and in the 60’s, introduced caribou to the island as an emergency food supply. With no predators, only hunting keeps the population in check.
The Navy abandoned the base about 20 years ago, tore down a lot of buildings, rendered safe the chemical and other weapons, and turned the island over, wholesale, to the Aleuts.
Today, the year round population has stabilized at about 300. Two jets a week land on a first-class runway; the TSA workers come in and leave on the jet. The island has two general stores, a cell phone shop, a self-service gas station (price per gallon $6.81,about twice what it costs at home), a division of the US Fish and Wildlife service, a school system with 5 teachers for 30 students, a restaurant, a post office, and a clinic staffed by a PA.
But housing for 6000 remains. A week’s visit gave me a taste of the mood of living in a ghost town: large numbers of uninhabited buildings, and a few energetic lively folks enjoying an island lifestyle with lousy weather. Everyone knows everyone except the tourists. Conversation and courtesy come easily.
Hunting, fishing, and birding tourism remains the main industry. The Aleut Native Corporation hopes to bring in commercial fishing facilities to compete with Dutch Harbor, and, eventually, a container ship dock to deal with the Northwest Passage and Transpolar routes. They already have the infrastructure.
Rain falls 340 days a year on Adak, and winds in January can exceed 100 MPH. Stuff made by humans rots and rusts, and becomes one with the island. No trees grow on Adak, but eagles frequent the streams where the salmon spawn, and walrus raise their young on a deserted corner.
In the airport on the way back to Anchorage, our party of 6 (two of us doctors) comprised the majority of those in the waiting lounge. I struck up a conversation with a young man who hadn’t come in on our plane. I asked if he’d been hunting.
No, he hadn’t, he’d been fishing. Commercial fishing, for halibut. Three days before, one of the crew members had started having asthma problems. The boat came to port but the crew member died shortly after arriving at the clinic.
The young man wore a haunted look. I didn’t know what to say.
I didn’t reveal my occupation.

Protected: Unemployed but not out of work

October 8, 2014

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Going walkabout again

October 7, 2014

The thirty days that they require

Has now come right past the wire

I think that it’s fitting,

Not quite that I’m quitting,

I’m hoping someday for re-hire

 

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 did two short assignments in Petersburg, Alaska.  On Sept 2, I turned in my 30 days’ notice.

I finished up my most recent job this week.

I liked the position, I had wonderful nursing support, and our new CEO has gone a long way to improve the problems that her predecessor brought on.

I got the chance to speak a lot of Spanish. Opening up my patient panel brought in a flood of pediatrics and young people.

I got to see pathology I wouldn’t get to see elsewhere, because of our patient population. I took care of many schizophrenics, with a high prevalence of Type I Diabetes.  East and West Africans came with a whole range of unusual problems including TB and its late consequences.  Rarely a week went by when I didn’t declare, “Weight loss in Iowa in the 21st century is NOT NORMAL.”

I also got a waiver to prescribe buprenorphine, a narcotic used to treat narcotics addicts. By Federal law, a doctor can’t get that credential without 10 hours of Continuing Medical Education and taking a test.

I learned a lot about narcotics addiction by getting my name on the national list. Opiate withdrawal turns out to be a lot worse than I’d thought, and takes weeks to conclude.  I developed my own mnemonic, DANDY LIPPS (dysphoria, aching, nasal discharge, diarrhea, yawning, lacrimation, insomnia, piloerection, pupillary dilatation, salivation) to remember the features.  Diarrhea, sleeplessness, and pupillary dilatation resolve after all the other symptoms have disappeared.

I learned other lessons about the ugly process of addiction. My own narcotics prescription habits have gone from conservative to stingy to the point where I baulked at 15 hydrocodone for a patient with well documented kidney stones.

The corporate subculture of functional, mission-driven dynamics and support made the work day go well.

Why, if my job had so many positives, would I want to leave?

The answer comes down to one item, the electronic medical record (EMR) system. Poorly designed and badly installed, I found it barely tolerable till June.  The vendor sent us an update without beta-testing, and the system slowed down from snail to glacial.  Clicking on a button would not bring a response in less than 20 seconds.  Clicking on a particular, popular button would guarantee a freeze-up that could only be fixed by the System Administrator.  I found myself spending more than 8 hours weekly watching an unresponsive screen.

One day the system kicked me off 11 times, with each sign-on costing an average of 5 minutes. At the end, I finished my documentations and started in on the queue of 35 messages from the Billing Department.  The first one took 14 minutes to complete, most of it involving an hourglass that didn’t seem to move.

I gave my 30 days’ notice and I did my best to burn no bridges. I left eligible for rehire, on such good terms that I’ll cover the 12/25 holiday.

In the meantime, I’m going walkabout again.

Another last week

October 5, 2014

Quite early to work I did sneak
To start when no one would speak
I will sing and I’ll praise
These last final days
And be done at the end of the week

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 did two short assignments in Petersburg, Alaska. On Sept 2, I turned in my 30 days’ notice.
My last week with the Community Health Center started with a really fantastic Monday. Away from the clinic for ten days for a hunting vacation, I looked forward to patient contact, but dreaded the crunch that comes from being away. So I arrived an hour early, and attacked the 35 items that had accumulated on my electronic desk top, mostly expected normal lab and x-ray.
Three thyroid items came unexpectedly normal, a welcome set of results for a family with no resources and no insurance.
Four items had to do with one of my buprenorphine patients. I had to get a special license to be able to prescribe this narcotic to narcotics addicts, and this particular patient had done well with counselling and meetings for 7 months. Despite warnings to the contrary, the quartet of ER documents confirmed that the patient took an off-the-street benzodiazepine (the drug class that includes Xanax, Valium, Librium, alprazolam, lorazepam and diazepam) and lost the will to breathe, which in this case necessitated CPR and an ICU admission.
Two of my other buprenorphine patients came; they have done well with the medication and watching them maintain jobs and families encourages me. That medication, however, like any other in my profession, lacks 100% efficacy. In fact, if I hit 20% with this particular disease state I count myself lucky. No drug does any better. I had to arrange for subsequent care for both.
No-shows kept my patient flow well within reasonable limits; I kept up with my documentation along with the steady influx of results and reports that have to be personally reviewed by the doctor. Also the numerous emails that accompany the end of employment.
I flew down the stairs to Human Resources to sign papers and learn about my benefits. I spent most of my exit interview talking about the stuff I love about my job.
Then I enjoyed a rare luxury: lunch. I ate my sandwich, smoked salmon salad with fresh basil lovingly prepared by my wife. For twenty minutes I savored the goodness without trying to work at the same time.
One of my schizophrenic patients came in for the monthly Haldol injection, and expressed sadness that I’d be leaving; we share an interest in history and frequently we surprise each other with our details. Well children alternated with diabetics, depressives, and hypertensives, and the afternoon slipped into evening.
And just when I started to wallow in how reasonably the day had gone, to barely start to wonder about my decision to leave, the computer froze, and I remembered why I turned in my 30 day notice 27 days before. I fumed. I muttered bad Navajo words under my breath. I had fantasies of throwing my computer out the window.
I left the office before 800PM to go to the gym, with only 5 documents left undone.

Meditation at 12000 feet

September 30, 2014

Into the mountains I sneak

To  camp by a lake on a creek

The permit I bought

To be alone with my thought

And remember the important third week

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 did two short assignments in Petersburg, Alaska.  On Sept 2, I turned in my 30 days notice.

 I went elk hunting in Colorado with a friend from Iowa and two friends from Colorado.

Acclimatization to altitude comes as a huge barrier to flatlanders hunting, and we flew out two days early to spend a couple of nights at altitude. Where before I announced I would never spend the first night in camp over 10,000 feet, I compromised this time.  We spent three nights at 8500 feet and then pitched our tents at 11,500.

I felt every foot of that altitude more than I felt every year of my age, 24 more than any of my companions.

Knowing the physiology helps understand the process of getting used to low oxygen, but it does not speed the process. By this time we’ve all learned the importance of maintaining good hydration.  And we’ve all come to a phase in our careers where we can afford good gear.

Along the way I took care of one person with a sprained ankle, another with posterior tibial tendonitis. I gave good advice to a person who drinks more than he should.

While the younger guys ran around canyons and rim rock, I spent most of my days pretending to hunt and being alone with my thoughts. I would put the cap on the muzzle loader and walk 300 yards along the edge of the glacial lake to a spot overlooking an elk wallow.  With spires of fractured granite towering a thousand feet over me, I watched the tortured landscape and thought about my upcoming career move.

My job brings me much satisfaction. I speak a lot of Spanish and I get to do a lot of pediatrics.  I work under top-notch management with great coworkers and outstanding colleagues.

But I cannot abide an electronic medical record system that parasitizes 2 hours a day in gratuitous delays.

The more I thought the better I liked my decision.

After the 7 mile walk out (at 12000 feet), the first shower in a week, the celebratory meal at the swank restaurant, and a night in a bed, we sat in the airport in Durango and struck up a conversation with another Iowan.

He walked from Denver to Durango along the Colorado Trail.

I didn’t ask what he thought about during those 5 weeks, but we talked about wildlife. And after a little bit I asked what day he started walking; I added 21 days to that and said, “On September 6 you had the start of a health problem.  What was it?”

I explained the three week rule, the summation of microtraumas accumulated in the course of accommodating to a new level of fitness.

And I thought about how I’ll have to watch out for the 21st day after I leave my job.

Three doctors over breakfast discussing contracts, diabetes, trauma and hearts

August 31, 2014

At breakfast sat down doctors three
The advice that we gave was for free
We talked about cases
And contractual places
And what we should charge for 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 still take short-term positions occasionally.

Three of us met on a Thursday at a popular coffee spot. Over trendy breakfast items and flavored lattes we discussed game theory and negotiating techniques.

A couple of Thursdays or Fridays per month have found us at a morning meal together for the last couple of years. We have guided each other through difficult items of a doctor’s career. We all face hard decisions for our lives and our life’s work.

We do not hesitate to give voice to good advice in the face of questionable choices, and we each have regretted not taking our own advice.

But yesterday we talked about getting a better offer. One who has no willingness to walk away from a deal has no bargaining position at all. We have all faced bait-and-switch situations; an employer has said one thing, made a deal, then unilaterally changed the circumstances. What can a doctor do?
None of us alone has more wisdom than all of us put together, and our group consciousness guides us to better decisions and actions.

We finished stronger than when we had started but we ran out of time and we still had cases to discuss. Because the business of being a doctor and the work of being a doctor are so intertwined. Come to my house tomorrow at 7:00AM, I said, I’ll make omelets and we’ll continue.

As dawn on Friday broke, I engineered quick but elaborate breakfast dishes. Jarlsburg cheese caramelized in the frying pan as the discussion started.

For reasons of anonymity, I will leave out who presented which patient.

An 18 year old female with thrush, or, at least, a painful mouth diagnosed elsewhere as thrush.
“Does she have HIV?” one asked. No, she didn’t, but that’s a good thought and the test came up negative. “How about the 3 P’s?” came the next question. Excellent, the presenter said, referring to polydipsia, polyuria, and polyphagia (drinking a lot, urinating a lot and eating a lot), the three signs of diabetes we all learned in medical school. Yes, she did; her sugar was 424. There followed a presentation about distinguishing Type I diabetes, where the patient will need insulin for the rest of her life, from Type II, where diet, exercise and pills can take care of the problem. We talked about 4 lab tests 2 of us had never heard of, and how the phone call to the endocrinologist (hormone specialist) went.

Then a case of wide-complex ventricular tachycardia with low blood pressure, a presentation classic from Advanced Cardiac Life Support, a course we’ve all taken. And after that, a death from massive trauma, complicated by legal and administrative issues and a difficult family situation.

As we ate mushrooms, onions, fresh basil, eggs and cheese, each of us filled in the human details, the heart-rending impact of disease as it ripples through the family, the community, and the hospital staff. By the time we finished we were better doctors.

Schizophrenia should not be a death sentence

May 1, 2014

Even the worst of the cynics
Support the function of clinics
It’s a seasonal flow
They come and they go
The homeless bipolar schizophrenics

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 just returned from my second locums trip to Petersburg, Alaska.
The young man I talked to in the clinic recently brought a distressingly familiar story; because so many have similar tales I can talk about the non-unique elements. From out of town, he couldn’t give me a good reason he had landed in Sioux City; he had no work or money and the word “tenuous” described his housing arrangements. As we talked the contradictions in the history started to add up, but I carefully avoided bringing inconsistencies to his attention.
I won’t discuss his “admission ticket,” the physical illness he described came second to his main problem.
A long, involved medical history with improbable descriptions of other health care facilities, led me to conclude that he maintained an uncertain relationship with reality, and, eventually, he mentioned his history of schizophrenia.
My 22 years as a co-owner of an upscale clinic brought me little contact with schizophrenics, but my current position has. Our facility cares for most of the schizophrenics in the city.
I have learned that schizophrenia, bipolar disease, and substance abuse overlap each other with terrible frequency. Most schizophrenics smoke, and trying to get them to stop ranks with trying to stop the tides. The majority of schizophrenics have difficult-to-control diabetes.
We have drugs to treat the bipolar, the diabetes, and the smoking. Yet we lack good, effective treatment for the basic disease process, where a person’s thoughts loses touch with reality.
(One very effective drug, clozaril, shows dramatic improvements not only in symptoms but functionality; the worst side effect, occasional and unpredictable bone marrow shut down, makes it too toxic for all but the most severe cases.)
Our society has failed our mentally ill. A Republican President with bipartisan support closed the mental hospitals and dumped the patients onto the streets. They form a disproportionate percentage of our prison and jail population and a majority of the homeless. Unable to cope with the real world, they can’t hold jobs, manage money or maintain interpersonal relationships.
If someone in our town stumbles out from under a bridge and into a clinic, they stumble into our clinic. They truly can’t afford to pay for their services.
The most conservative, fiscally stingy, small-government supporters I know agree that schizophrenia should not be a death sentence.
Some of my schizophrenics can maintain a semblance of a normal existence with regular medication; a few can manage part-time employment. But many just keep drifting, north in the summer, south in the winter.
I do what I can for them, recognizing the fleeting nature of the relationship.

Dead doctors and AAA batteries

April 9, 2014

This one’s about a dead cell
That leaked, and corroded as well
I got over that quirk,
And made the thing work
After only a very short spell

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 to have adventures and work in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center. I have just returned from a one month locums assignment in Petersburg, Alaska.
In 1989, my then-partner said, “Well, it’s like when you make rounds on Christmas. You start early, you put a Dictaphone in your pocket and you go like mad.”
Sitting at a stoplight on the way home I thought about what he’d said and decided to round as efficiently as possible every day. Later on, when I started doing the hospital work for my group, I started to carry a dictating machine to save time. The alternative required finding a telephone, and entering the following digitally: physician number, dictation type (progress note, discharge summary, etc.), and patient medical record number. As years passed each hospital required more info and developed more pauses before dictation could actually start. Both hospitals shift their equipment every 2-3 years, requiring purchase of a new dictating machine, generally for about $600. With every passing year that purchase brings an increased efficiency over phone documentation.
The last of the handwritten progress notes died two years ago. By then I had figured out how to dictate while walking from patient to patient.
This morning I slipped my hospital-specific digital recorder in my pocket and started rounds at 7:00AM, finding the machine would not turn on. As always, I looked to battery replacement as the first fix, and the pediatric head nurse brought me two new AAA cells, but to no avail. While I grumbled, she took the batteries to the recycling bin, commenting that, as one had leaked, much time must have passed since last I used the machine.
New in mid-January, those batteries saw scant use till late February and no use after; I thought neither period qualified as a long time. I removed the new cells and spotted corrosion on one of the terminals. I went to work with a pencil eraser, cleaning the metal to shininess. I recalled how, in previous years, I repaired so many tiny tapes with scalpel, forceps, and Scotch tape I almost wrote an article, Microsurgery for Microcassettes.
I know batteries go bad, but I have never seen a battery go from new to leaking in less than three months.
Then, with the digital recorder working well, I started on rounds.
At lunch in the Doctors’ lounge, I sat down to a conversation in full swing on the subject of death. One of our ophthalmologists passed away a couple of weeks ago without warning. Then we all remembered the cardiologist who died young on a treadmill, and the orthopedist who died, gratuitously, of colon cancer. In short order we shifted the topic to nature vs. nurture in the realm of colon cancer, heart attacks, alcoholism and cirrhosis.
While the other docs talked, I ate hospital chicken and rice, and thought about batteries leaking and corroding after premature failure. And I rejoiced in the time I’ve spent doing locum tenens.
Carpe diem.


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