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.

Road Trip 3: Thick New York traffic while listening to the collapse of societies

November 2, 2014

The traffic makes New York a mess
Despite a new GPS
But I got quite annoyed
The tolls to avoid
Added 10 hours, more or less.

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.
Just before leaving Sioux City, I bought a new GPS unit for the trip. I named her Samantha.
Sweet heart, the GPS who guided us through my year of walkabout, had psychotic tendencies. From time to time, her screen would turn purple and she would demand a left turn in inappropriate places, such as boreal wilderness or the middle of a bridge. The simple universal Microsoft fix, turning off and turning on, worked well, but she took to losing contact with reality so frequently that we retired her and gifted her to a friend who rarely leaves town.
We bought her successor while in route to St. Louis, but I ruined her by attempting an update.
With the passage of two years, all car GPS systems have improved. Samantha gets traffic updates (I don’t know how) on a regular basis. I advised her in the beginning I didn’t want her telling me to make U turns, and when I left Pittsburgh, to get her semiconductors to avoid the Pennsylvania Turnpike, I told her to avoid tolls. Thus I got onto I-80 but didn’t realize I’d added 600 miles to a 300 mile trip till the middle of northern Pennsylvania.
With leaden skies over spectacular fall colors I proceeded east, and traffic thickened. Road kill possums, raccoons, and deer by the dozen lay in mute testimony to Newtonian physics.
Still, I maintained good average speed till the George Washington Bridge. Appropriately, I listened to an audio book on the collapse of societies while idling in coagulated traffic. I thought about Adak Island, where, less than three weeks ago, we marveled at seeing four vehicles moving at the same time. I decided that between the approaches and the span proper, the GWB held more pavement than the entire island where I’d hunted caribou, and possibly more than all of the Aleutians put together.
With jangled nerves, I picked Bethany up at the airport. Exiting proved beyond Samantha’s capabilities. With the experience of three laps through the maze, we figured it out.
I hope to drive in New York City as little as possible.

Road trip 2: Cincinnati to Pittsburgh. On dealing with a flakey recruiter

November 1, 2014

I said yes but I’m waiting to hear,
While I drive and I brake and I steer,
Not quite my ideal
But the opportunity’s real
And it might last for more than a year.

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.
Having fewer time constraints means more leisurely travel.
Today I slept in till 0730, took my time at breakfast, talked with recruiters, did laundry, packed, and left for Iowa City about noon.
I told the recruiters my ideal job situation: a hospitalist position in Alaska, working alternating weeks, and avoiding the ICU. One recruiter chuckled appropriately, noting that few hospitals exist in Alaska, and perhaps I’d be interested in a similar position in Maine?
Another talked about getting me into a hospitalist position in Gallup. I said, Dine bizaad shilth bahozin ndi doo hozhoo da, and immediately translated, “I speak Navajo but not well.” And a wave of Navajo memories came flooding back. The recruiter expressed amazement, and we agreed such linguistic skill would be a good marketing point. The spot pays 60% of what most hospital positions pay. Still, I think about it seriously.
Maybe, I said to both, but right now I’m waiting to hear back from a recruiter working on a spot close to my ideal, but 4 highway hours from my house, and let’s get in touch on Thursday.
The morning’s email also held an offer for a position in the Alaska interior. They want a 3 month commitment, but the job has appeared over and over in the last two years, and I suspect they might be able to flex if I offered them, say, 18 continuous days on, then 7 continuous days off, enough time to fly home. I slid the email into my Locum Tenens folder.
I munched sunflower seeds and high-quality chocolates all the way to Iowa City. I talked to two more recruiters on the way. I confirmed my ideal situation, discussed where I can flex and where I can’t. One told me about a spot that has gone empty for quite a while, a six-hour drive from home. Can’t fly there? She asked. Nope, I replied, one can only fly from Sioux City to Chicago.
After an uneventful drive, over curry and naan and saag paneer in Iowa City I got to recount some Alaska experiences and the surrealism of Adak Island.
When I checked my email this evening I found a different agency offering the same position 4 hours from home I’d said yes to, and right under that an email from the recruiter I had spoken with. They just wanted you for Thanksgiving week, he said. And I faced a conundrum.
On a moral basis, I owed the first recruiter my business, but the second outfit looks a lot more professional than the first. So I replied to the first recruiter that another agency had offered me that spot, too, and not for just a short-term, and should I go ahead and have them present me for the longer term?
I’ll hear back tomorrow.

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.


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