A Canada license takes time.

August 28, 2015

I wait, and I don’t get a call

About Canada and the upcoming fall

I’m a little bit vexed

What shall I do next?

I’m about at the end of my stall.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

Work proceeds on my Canadian license.

Just as each US state has its own medical licensure board, so does each Canadian province.  Just as once licensed in, say, Wyoming, getting licensure in Colorado becomes much easier, similarly a license in British Columbia will make other Canadian licenses less complicated.

My New Zealand license worked for the whole country.  I never even learned all the districts.

But the first Canadian license takes a lot of time.   I started in April.

In New Zealand, compensation came as a package, with no room for negotiation.  The agency got all its funding from the state, and took nothing from either the doc or the client.

My Canadian recruiter receives a finder’s fee from the client, but the doc negotiates directly for compensation, transportation, and housing.

In the US, the recruiter negotiates things like rate, which always includes transportation, car rental, housing, and professional liability insurance.  Those negotiations represent value and labor, and the recruiter gets a chunk of the total package.

Thus less of the total pie in Canada goes to the recruiter and more to the doctor.

The process has gone slowly.  So slowly that I have started to question the viability of an October 6 start date.  Part of the problem stemmed from the 2 weeks’ vacation taken by a key player in the licensing process, another part came from unclear expectations for documentation.

Bethany and I have started talking about where we want to go if Canada falls through, and we came up with Wyoming, Navajoland, Alaska, and Puerto Rico.

We’d like to go back to Wyoming, where we originally met, and, after our experience in Alaska, the idea of the winter doesn’t scare us.

When we arrived in Navajoland I had just finished residency, our first child hadn’t had her first birthday, and we grew together as a couple there.  The Indians taught us a lot about hospitality, and I learned to hunt there.  We’re both curious to see what has happened to the culture in the last 30 years.  And certainly the culture has changed.

I’ve now made seven trips to Alaska.  It’s a very, very big place, and I’ve only scratched the surface.  I’ve not experienced the interior or the Mat-Su valley.

Bethany suggested Puerto Rico because living there would force her to learn Spanish.

And, all in all, we’d rather have a good spot in Wyoming than a bad spot in Puerto Rico.

But the American Academy of Family Practice’s Annual Scientific Assembly starts in a few weeks in Denver, and I know that I’ll be able to talk to dozens of recruiters.

I estimate my exercise output and my caloric intake badly

August 27, 2015

How much was it I ate?
I don’t know, but I can estimate
I know that I guessed
And it wasn’t the best
But there’s no denying the weight.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

Most Americans struggle with their weight because human beings are lousy estimators. We badly estimate how much exercise we got and we badly estimate how many calories we have in front of us, and our waist lines slowly expand.
Working Urgent Care, I can eat a decent breakfast before work. I don’t take a formal lunch or dinner break. Sometimes I get lunch, and sometimes I don’t. I will, as instructed, eat enough to keep making good decisions, which generally means stepping into the break room in the midafternoon and wolfing down some provided snacks (I prefer Goldfish and peanuts).I try not to eat supper, because, like the majority of Americans, I struggle with my weight. Mostly, I fail, and I end up eating something when I get back to the hotel. I try to keep it light. I don’t always succeed.
When I used to work 12 and 14 hour days in private practice, I could exercise after work because my day started at 5:15AM, but the 8:00 to 8:00 schedule precludes exercise late or early without significant loss of sleep.
Wednesday, when my work week finished, I ate supper, and next morning ate an enormous breakfast. The trip home met with delays and cancellations, and the airline provided us with meal vouchers. Bethany prefers to travel hungry, but with 6 extra hours at Chicago Midway, I used all $24 to buy a mushroom torta, chips, and guacamole. I ate with guilt, aware I’d missed a lot of gym sessions and I hadn’t missed enough meals. Which didn’t keep me from snacking on chocolate almonds while the next plane boarded late.
One of our friends drove down from Sioux City to Omaha to pick us up. We drove back in the dark, arriving home to face two weeks of mail, neatly laid out on our kitchen table.
The next morning I gritted my teeth before I got onto the scale.
To my surprise, I’d lost 4 pounds in the two weeks we’d been away.
I didn’t snack as much as I thought. But I also have to figure that I got more exercise in the course of a day’s work than I’d realized. A pedometer would give solid numbers.
If you estimate well, you can generally find work, well, as an estimator. My track record on estimation, poor at best, keeps me out of that line of work. Which means I’m a lousy estimator.
Like most human beings.

Trade offs in Urgent Care

August 11, 2015

I enjoy my Urgent Care job
The patients come by the mob
But sometimes it’s our fate
We’re not done, but it’s late,
The rush just makes the staff sob.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I enjoy my current gig for an Urgent Care facility in suburban Pennsylvania.

My nominal work hours run from 8:00AM to 8:00PM. I go late on average one night out of three. Patients generally come in with problems of short duration and intense acuity. Most have a primary care provider who can’t see them in less than 3 days. Because management has developed a patient-centered approach, I do little redundant clerical work and thus I can spend a lot more time concentrating on patient care.

So far this week slow patient flow in the morning has given way to a brisk pace in the afternoon. Staff morale stays high, the big gripe comes against the rush of patients that starts after 7:00PM (about half the time). So tension builds on quiet nights as the clock ticks out the last half hour.

Poison ivy made up half the business back in June, but is now decreasing in frequency and severity. I have sewn up a lot of finger and hand lacerations. Two or three times a day we have the joy of curing the patient before they leave, mostly by taking out ear wax; but we also drain an average of one abscess a day. A majority of the x-rays I order show fractures.

People around here like to vacation at the beach, mostly New Jersey,Virginia and the Carolinas. We get a significant number of patients with swimmer’s ear and urinary tract infections related to the travel and swimming. And also the worried well who don’t want to be sick while on vacation.

August brings in the sports physical crowd. Basically healthy, the rare surprise disqualifications justify the activity.

Then, sometimes, with such a high patient volume (I consider 30 in a 12-hour shift light), serious illness demands an ambulance or an injection. Twice so far today I’ve advised patients to go directly to ER.

Earlier this week I helped wheel a patient into her waiting vehicle. I enjoyed breathing the warm summer air and smelling growing vegetation and seeing the summer thunderheads building in the north.

Occasionally a physical finding I’ve never before seen heralds a puzzle, and I refer to a specialist.

We refer all broken bones to orthopedists.

Urgent Care has its share of joys but so much of the fun comes from the fast pace and the easy-to-solve problems that the awe and mystery of unraveling complex disease one lab result at a time gets lost. An upscale, insured population obviates the opportunity to serve the under-served. And I miss speaking Spanish.

Life always involves tradeoffs.

9% Grade: New Bethlehem to Kittaning

August 9, 2015

Many the story I’ve told,
About the horrible hills I once rode,
I know where I’ve been,
To ride them again
Would ignore my life’s lesson code.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I finished my first undergraduate career in 1972 with no plans for the future aside from bicycling back from New Haven, Connecticut home to Denver, Colorado. I went with Al, a roommate for 2 years.

I sent my winter clothing, bedding, and books parcel post. I looked at everything else I owned and divided into two piles: one to take with me and one to throw away.

The trip changed my life. Four years later I sat in a small room in East Lansing, Michigan, at my fifth and last medical school interview. The first four had gone poorly and I saw my last opportunity at my life’s goal hanging in the balance. In desperation, I spoke from my heart on what I learned that summer about the rhythms of the earth from lessons in bike repair, camping, weather, traffic, and minimalism. That interview ended up a fantastic success, and I got a place at Michigan State.

I started the trip with 32 pounds of gear and finished trip with 26; the bicycle weighed 34 pounds and did not change materially. Bicycles became embedded in my life that summer; I bought Bethany a tandem instead of an engagement ring.

In the summer of 1975 I rode from Denver to San Diego in 11 days, and over the years I commuted so many miles that I could look at a derraileur and say, from experience, that it would only last for about 5,000 miles.

The worst hills I could remember came that first long trip, in the 19 mile stretch from New Bethlehem to Kittaning, on Route 28 coming into Pittsburgh from the north. It took us three hours, and we didn’t know if we could make it the rest of the way to town (we did).

But sometimes a forty-year lens magnifies misery. I wondered if that stretch really had that many steep hills; on my day off I decided to drive it in the rental car.

Coming north from Pittsburgh, I recounted to Bethany the horrors of that trip, and wondered aloud if it really had been that bad.

Yes, it had been, long steep grades separated by no more than 50 yards of flat. One sign, coming into New Bethlehem, that we wouldn’t have seen from a bicycle headed south, said “9% GRADE TRUCKS USE LOW GEAR.”

Nine percent?

NINE PERCENT??!! A railroad can’t climb anything steeper than 6%; neither Casper Mountain in Wyoming nor Mount Taylor in New Mexico came close. And this thing went on for a couple of miles, and dropped almost as badly on the other side.

With such focus on steepness, I failed to remember the narrow and sometimes non-existent shoulder.

I thought back to other superlatively negative experiences: high school, the worst night on call (38 hours with one 45 minutes break), the heaviest clinic day (63 patients in 6 1/2 hours), the worst Electronic Medical Record (Centricity).

I accept my memories as accurate, I don’t have to do those again.

Iowa house calls, back to Pennsylvania

August 7, 2015

For a house call I went to a store
Then expected one or two more
To come to my house
So I said to my spouse,
They’ll come in through the front door.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

While home in Iowa last week I made a couple of house calls.

One patient owns a business I frequent, and had called me when we were both on the way back to Iowa. Our professional relationship dates back well into the last century. We have watched each other progress professionally and socially. He gave me the go ahead to write the entre visit in this venue as a record, but, for the same reason I conducted the interview on the deserted freight dock and the exam in the store’s quietest corner, I didn’t. At the end, he personally helped me with my selections and would not accept money for the transaction; nor would I accept payment from him.

Another friend has had a problem building for months; we agreed on the next step: the specialist.

The garden has come in, and Bethany and I snacked on the first of the tomatoes, cucumbers, and green chiles; We invited company for supper on Friday. For a side dish, I cut sweet corn from the cob, added red onion, roasted green chiles, lime juice, and olive oil.

I took call for my Community Health Center the weekend. One patient discharged from peds on Saturday and one admitted on Sunday,far cry from a census demanding two docs to round both mornings, with one up all night to take admits and calls.

Tuesday found us back in Pennsylvania, at an Urgent Care, working 12 hour days, but this time we can walk from the hotel to the clinic. I like the medical record system. I can whiz through documentation for respiratory problems, but skin and musculo-skeletal problems need more narrative because no two are the same. A disproportionate number of patients come in with poison ivy.

Urgent Care, by definition, doesn’t include ailments that need follow-up or CT scans. I sent a number of patients each with suspected heart attacks, blood clots, or kidney stones to the local ER. People with bipolar disease tend to have very real, severe physical problems. I can treat those injuries, but getting at the root cause falls outside my scope of practice.

To those patients who come in, for example, with weight loss (now into the double digits working for this client) I say, “This is not normal, but there is a limit to what can be known an hour, and there is a limit to the lab we can run in Urgent Care. You need a primary care provider, and here is a list of labs that he or she might run.”

Nor can I effectively treat rheumatologic problems, but rheumatologic patients come to see me nonetheless. From time to time I run into people on Enbrel, and then we generally have a happy support group meeting. We talk about how the drug changed our lives; how, coming out of the pain we could engage emotionally with our families; and about how, outside the pain relief, we just feel better; (I feel better now than I did at age 18).

If I talk to a back pain patient on opiates, I tell them how the medication inhibits their own ability to make endorphins and perceive endorphins. Some express shock and amazement, and some just want me to prescribe the Norco, because “it’s the only thing that works.”

The script our parents give us

July 22, 2015

To the problems I can relate
My family was in a sad state
Let’s call a halt
To blame parents’ faults
We’re obliged to master our fate.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

After a week off, I addressed the drama and irony behind the first patient’s very real physical problem from the perspective of my own experience. My mother had borderline personality disorder, my father had narcissistic personality disorder; no medication exists for either of those two problems. I observed that we don’t get to write the script that our parents hand us, but we have the obligation to edit it, and that obligation gives us freedom. Stressed people get sick, and sick people get stressed. Some of the stress that life brings us we cannot avoid and we just have to deal with it, but some of our stress we make for ourselves.
I saw a lot of people sick in the aftermath of a death in the family. For some I mentioned my brother-in-law’s untimely drowning and we had a mini support group. With others I talked about my 11 culture proven strep throats in the 10 months after my mother’s death.
Early in the day I recounted two stories to the PA I worked with. The first had to do with a different clinic in a different century, during the days of paper charts, when I caught myself over emphasizing the importance of thyroid testing to a med student. “Think thyroid!” I pontificated. “Depression? Think thyroid. Weight gain? Think thyroid. Weight loss? Think thyroid. Diabetes, hypertension, or cholesterol? Think thyroid.” We walked up to the next exam room, and I pulled down the chart so we could read the chief complaint on the routing slip.
“C’mon,” she said, “Sore throat? Think thyroid?”
And with a trifle more certainty than my experience justified, I said, “Think thyroid!” We walked into the room, I said to the patient, “Take one finger and point to where you hurt the worst.” She pointed to her thyroid, and turned out to have Hashimoto’s thyroiditis, with an anti-TPO about 100 times the upper limit of normal. I hope the med student recognized the luck that played into that impressive bit of diagnosis, but still went on to test the thyroid for the least justification.
The second story had to do with a patient in another clinic in another state, who might have come in for one thing but routine exam picked up an irregular heartbeat and EKG showed atrial fibrillation.
All in all, the day went well. The PA stayed till 2:00PM. I ordered delivery Chinese, and inhaled forkfuls of fried rice between patients.
The last patient of the day teaches high school history. We had a marvelous but all too brief conversation about that subject. While some might complain that current history curriculum includes an excess of politically correct material, I remember clearly the Cold War propaganda from my own high school days; we students recognized that material as a pack of lies. Which inspired me to study history on my own, and to find out the real story.

Horse rescue, poison ivy, and Irkutsk

July 22, 2015

If your work brings you down in a ditch
Poison ivy can bring a bad itch
For the leaves that are three
You should just leave them be
And Zanfel fills in the niche

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

From time to time I ask patients to include some of the fascinating details of their lives in my blog. I leave out diagnosis, age, and gender unless relevant to the story, whether the patient gives permission or not.
I had a fascinating conversation that started with my use of a few well-pronounced words in Russian. The patient peered at my name tag, and observed that my last name didn’t look Russian. Perhaps not, I replied, but we had that name for a thousand years in Lithuania; when the Mongol era globalized trade, the king of Lithuania imported Scots traders to try to build a middle class. In short order, I revealed my grandfather’s fleeing Tsarist Russia east through Irkutsk, the patient’s birthplace; and in turn learned of the patient’s Yupik heritage. So I could tell of the man I met in Nome whose family had fled from Stalinist Russia to Alaska in an umiak. At the end, I said “thank you” in both Russian and Inupiaq.
Another patient works on a large animal rescue team. During a lull I quizzed the patient about work, and listened, fascinated. The medical problem was routine, the horse rescue anything but.
I see a lot of poison ivy problems here, and I can always find a story in how it happened. Usually it comes in the context of social stress, frequently marital discord. But sometimes it happens in the course of work. On more than one occasion I said, “If you’re the boss and your crew works outside, it’s worthwhile for you to get a case of Zanfel and hand it out and tell them to cleanse with it if they start to itch. And you can probably get a case of the stuff for less than the price of two doctor visits.”
I’ve had to learn a lot about poison ivy. Non prescription Zanfel does a good job of binding the resin away from the skin (hence my recommendation). Systemic steroid use less than two weeks usually results in rebound itch and a phone call, and is not justified if less than 10% of the skin is involved. Hydroxyzine is a powerful anti-itch medication that doubles as a sleeping pill. And most people can handle the itch during the day, but they come for relief because they can’t sleep.

Thinking thyroid, learning history

July 21, 2015

Here’s something that we should note
For a diagnosis I’ll throw in my vote
When it comes to life’s stress
The immune system’s a mess
Is it really just a sore throat?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.
After a week off, I addressed the drama and irony behind the first patient’s very real physical problem from the perspective of my own experience. My mother had borderline personality disorder, my father had narcissistic personality disorder; no medication exists for either of those two problems. I observed that we don’t get to write the script that our parents hand us, but we have the obligation to edit it, and that obligation gives us freedom. Stressed people get sick, and sick people get stressed. Some of the stress that life brings us we cannot avoid and we just have to deal with it, but some of our stress we make for ourselves.
I saw a lot of people sick in the aftermath of a death in the family. For some I mentioned my brother-in-law’s untimely drowning and we had a mini support group. With others I talked about my 11 culture proven strep throats in the 10 months after my mother’s death.
Early in the day I recounted two stories to the PA I worked with. The first had to do with a different clinic in a different century, during the days of paper charts, when I caught myself over-emphasizing the importance of thyroid testing to a med student. “Think thyroid!” I pontificated. “Depression? Think thyroid. Weight gain? Think thyroid. Weight loss? Think thyroid. Diabetes, hypertension, or cholesterol? Think thyroid.” We walked up to the next exam room, and I pulled down the chart so we could read the chief complaint on the routing slip.
“C’mon,” she said, “Sore throat? Think thyroid?”
And with a trifle more certainty than my experience justified, I said, “Think thyroid!” We walked into the room, I said to the patient, “Take one finger and point to where you hurt the worst.” She pointed to her thyroid, and turned out to have Hashimoto’s thyroiditis, with an anti-TPO about 100 times the upper limit of normal. I hope the med student recognized how much luck played into that impressive bit of diagnosis, but still went on to test the thyroid for the least justification.
The second story had to do with a patient in another clinic in another state, who might have come in for one thing but routine exam picked up an irregular heartbeat and EKG showed atrial fibrillation.
All in all, the day went well. The PA stayed till 2:00PM. I ordered delivery Chinese, and inhaled forkfuls of fried rice between patients.
The last patient of the day teaches high school history. We had a marvelous but all too brief conversation about that subject. While some might complain that current history curriculum includes an excess of politically correct material, I remember clearly the Cold War propaganda from my own high school days; we students recognized that material as a pack of lies. Which inspired me to study history on my own, and to find out the truth.

Broken computer: condensing a week’s adventures into 500 words.

July 13, 2015

No way to write for a week

Of the wisdom and truth that I seek

The inevitable token

Of the computer that’s broken

Is not for the heart of the meek.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

I sat in a lovely Pennsylvania hotel room tapping on my tablet.  With the July 5 post, including limerick, ready to go, I started in on the post for July 6.

I wrote the July 4 post the night before and published it that morning, after a good workout on the elliptical.  And publishing more than one post a day seems to me excessive.  When I can write ahead, I do.  Because sometimes the work goes late and I’m too tired at the end of the day to post.

I had gotten halfway through the limerick for July 6 when my tablet screen flickered once and went black.  Twenty minutes later, past denial, anger, and bargaining, I accepted that the lightweight computer had ceased functioning and I couldn’t revive it.  Nor could I write about the immediacy of my days; I would have to wait to return home to condense a week of adventures into 500 words.

I met really interesting people and I had much to write about.  I quieted frightened febrile children.  I prescribed a narcotic pain medication on the basis of a breathtakingly abnormal x-ray.  Under tight time pressures, I cut my motivational interview to the bone and got astonishing results, better than I ever did when I could give the patient an hour.  With not a spare second for judgementalism, smokers and drinkers decided to quit in front of my eyes.

I received no permission to write details about the psychiatric emergencies that I saw, but I can discuss the distilled lessons on the human condition that came from those cases.  Never put the keys to your happiness in someone else’s pocket.   Irrational behavior cannot elicit an appropriate response.   Families of psychotic patients suffer; the one who suffers most from physical manifestations of severe psychiatric disease most loves the person who loses contact with reality.

I took care of a lot of people before and after vacations.  The local patient population likes to go to the Atlantic seashore from New Jersey to the Carolinas.

Power went off briefly at the end of a clinic day, but not long enough to impact clinic function.

I had to give bad news over the phone several times, no patient expressed surprise.

I took time to grieve with those people sickened in the context of death of a loved one.  I brought comfort to them pointing out the force of human love derives from the fact of our mortality, and would be impossible if we lived forever.  I didn’t always footnote the source of that idea (a passage found in a prayer-book in the 80’s) and let it stand on the force of its obvious truth.

At the end of a heavy work week I turned down the prospect of time-and-a-half for another day’s work because of fatigue.  I visited my two married daughters and their husbands for three days.  I had lunch with a childhood friend.  I took away wisdom and learning with quiet joy, and flew back to Iowa.

Work on the glorious 4th

July 9, 2015

At one time I really liked running
The effect can be rather stunning
But a fracture from stress
Can make an ankle a mess
And test out all of one’s cunning.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania.
Any patient information has been included with permission.

I started running in high school. My then undiagnosed hypermobility syndrome, combined with inadequate shoes, a penchant for running on pavement, my obsessive tendencies, a teenager’s natural urge to test limits and my sheer stubbornness resulted in stress fractures of my lateral malleoli, the outside ankle bones. I gave up running after my first (and last) marathon in 1981, and in ensuing years I have diagnosed stress fractures in fewer than half a dozen patients.
Thus my first patient on July 4 and I had a runner-to-runner conversation about stress fractures, the meaning of running, and what to do when you can’t run.
The pace of the holiday picked up after that, with 5 or 6 patients per hour. I got further and further behind on my dictations. I plowed ahead, happy to be back at work after two weeks absence.
The holiday did not bring an appreciable change in the case mix or demographics: lots of poison ivy and respiratory infections; about 40% of the patients under the age of 18. Nor did I see a single fireworks-related problem. But I saw more out-of-towners and people just back from vacation.
While I sewed up a laceration, I had an excellent discussion about knives and cooking with the patient. I got to recount the part of my New Zealand adventure involving sharpening knives to a razor edge on the back of a china plate.
About 1130AM I started calling to find out what Asian restaurants would deliver on the holiday. Too hungry for my own good, I splurged on sushi, but didn’t get a chance to get to the break room till 2:00PM, when the PA arrived. I bolted soup and seaweed salad and sushi, and, as the pace slowed down, I started catching up on my documentation, having fallen 14 behind.
I cleared the backlog. I joined the conversation. One of the nurses made a Dunkin Donuts run (I didn’t participate, but I finished off my sushi). With patients trickling in at 1 or 2 per hour, a quiet tension set in, waiting for the 759 PM deluge that never materialized. I left, hungry and tired, at 803 PM and drove right to the hotel.
I ordered a burger in the hotel restaurant at 820PM. The waiter visited me 5 times in the ensuing hour, while I read Teddy Roosevelt on my smartphone. The chef had variously just gotten back from break, gotten swamped, or gotten the order wrong. I found trying to stay awake harder than enduring the hunger. I started munching my sandwich, too exhausted to taste, at 920PM.


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