Patient might share 2 diseases with me

August 14, 2022

There’s a problem with the bones of the spine

The x-ray looks awfully like mine

The problem is complicated

Inflammation is implicated

I hope I’m wrong and the patient is fine.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

Staffing shortages come for a lot of reasons.  Doctors are burning out and aging; some met their financial goals and re-evaluated their lives when they saw so many friends and colleagues die.  Some had problems with financial viability during the pandemic and decided to step out early.

But the same pandemic that hit the doctors hit the nurses (and the police and the retailers and the service industries, etc., etc.) Thus, lacking staff support, my work week would start on Tuesday. 

A good thing I didn’t have much planned for the day.  The VA called to tell me I qualify for tixagemab/cilgavimab (trade name Evusheld), an injectable medication designed to prevent COVID complications for 6 months.  I had never heard of it.  But I looked into it and decided to take the offer.  I could make the trek to Sioux Falls, and return to my current assignment the next morning without having to drive all the way back to Sioux City. 

I got the injection at the VA’s Infusion Center, the same place where they give cancer chemotherapy.  After a couple of needles, they made me wait for an hour. 

I spent 5 hours driving that day.

On Tuesday fully 1/3 of the patients came in for back pain.  Not just common back pain, but complicated back pain lasting months, going down one leg or the other, and each one had at least one red flag symptom: numbness, weakness, loss of bowel or bladder control, morning stiffness.  Each one met criteria for MRI. 

Normally, 5 lumbar vertebrae separate the rib part of the spinal column from the pelvis.  One of the patients has a transitional 5th lumbar, with one side fused to the pelvis, and had known it since adolescence (and gave permission to write about it).  I also have the same x-ray finding, which kept me out of Viet Nam and probably saved my life. 

I can hope we don’t also share ankylosing spondylitis, but I have to look for it.

I found another case of vitamin B12 deficiency, and started investigation on 2 other borderline levels. 

I saw 12 patients, ages 16 to 87.  I knew 2 from previous visits.  One had responded to my motivational interview techniques for tobacco (get the patient to first say 3 good things about it, then 3 bad things, repeat in a non-judgmental fashion what they said, then ask, Where does that leave you?).  He happily reported complete cessation. 

Which made my day.

Statins: not for primary prevention after 75

August 11, 2022

The name, well, I’d seen it before,

But here, they don’t have a score

The order made it to me

How? I can’t see

In the end, I just dodged the chore.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

In Iowa 40 years ago we used to say about the corn crop that it should be “knee high by the 4th of July.”  In fact this July 4th  it came up to my shoulders.  Despite a lack of rain.  Selective breeding of corn has given us strains that withstand drought.

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I recognized the name of the patient whose imaging order crossed my digital desk top today, but I couldn’t find a note in my name.  I hunted through the electronic medical record (this one is better than most).  The order made me uneasy, and a quick stroll through other doctors’ notes worried me more.  Finally I realized that everything has a geographic imperative.  The patient lives in South Dakota and attends a VA clinic there.  Yes, I worked with the VA there several months ago, but I have no idea how the order came to me for signature.  After 6 phone calls, the consultant knew where to send communications, and the VA facility knew to expect more information. 

Luckily the clinic started slow.  But I got to talk to my friends and previous co-workers in the VA. 

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Two new Parkinson’s patients this morning, one decided to try carbidopa/levodopa (trade name Sinemet), the other decided not to.  And I had a return Parkinson’s patient, doing well.  Another patient with a long medication list had problems with vomiting, and want to attribute it to medications.  Heck yes, I said, ABDC: Always Blame Chemicals and Drugs.  I went on to assert that the side effect probably came from a drug I prescribed, but the patient wanted to blame a different drug.  Which I consider a legitimate option.  The future will tell.

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We have a class of drugs properly called the Hmg Co-A Reductase Inhibitors but popularly called the statins.  They do a good job at preventing heart attacks and strokes in people with risk factors, especially if those factors include previous events.  But they also make muscles hurt.  Two patients today demo’d the drug class’s weak points.  One had improved greatly after stopping the statin.  The other had mysterious leg pain, and I advised halting the drug while we get some blood work, and, if necessary, an MRI. 

This post comes out of sequence.

No-shows and vitamin deficiencies

August 10, 2022

Planes are fast, it’s true, one the one hand,

But things never go as we planned

This summer my fate

Includes arrivals so late

You can never tell when you’ll land

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

This phase of my career has thrown me into a lot of air travel.  I came to the conclusion years ago that 1 in 5 flights will involve a major glitch.  So far this summer we’ve flown 4 times.  Every trip out went smoothly and every trip back had a delay of 2 or more hours.  We missed the connection for our trip back from Israel.  And though we had planned to land on a Sunday night with plenty of time to drive back so I could work on Monday, we had delays followed by drives, and couldn’t get more than 4 hours of sack time before heading to the clinic. 

I attended 13 patients Monday, because one patient didn’t come.  Two patients over the age of 90, 2 under the age of 1 year.  Five patients had joint problems: ankle, knee, back, and foot.  I found two new Parkinson’s patients, one early and subtle and the other fairly obvious.  Both decided to try carbidopa levodopa (trade name, Sinemet).  I look forward to seeing them improve.

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Tuesday ran light.  I attended 12 patients, got a chance to take a substantial nap over the noon hour, and went for a bicycle ride after work.  3 patients didn’t show.

Actually, more than one arrived 20 minutes or more late.  From experience, such patients don’t respect the time constraints of others.  They don’t hesitate intruding on another person’s visit, and will generally keep the physician occupied for more than an hour.  And, when I had my own practice, they didn’t pay their bill.  If the patient arrives more than 15 minutes late now, I request a reschedule.

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Today, Wednesday, 12 patients graced my schedule.  Of those, 7 kept their appointments.  Two called to say they’d overslept and rescheduled for later.  When they hadn’t arrived for the second set of appointments, we called.  They were still in bed. 

I took my time going through lab work from earlier in the week.  I found that 2 patients have vitamin deficiencies (two B12s and a folic acid), and later in the day found another probable B12 deficiency. 

Knees and hips dominated the case work. One patient had good joints but a puzzling clinical picture. 

I finished the clinic day early.  After a short bicycle ride back I took a nap, my 3rd of the day. 

I have almost caught up on my sleep.

Not violence, but heat

July 25, 2022

Of his work he never will tire

He welds, with his left he holds wire

But his gloves can be beat

By his labor’s heat

And the rash is redness from fire. 

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, traveled and worked in out0of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

Part of my exam includes checking a patient’s hands.  I watch how much they move or don’t move.  I can see expressiveness.  Some of the earlier signs of Parkinson’s can show up as a quivering of the muscles between the thumb and forefinger.  But I also do a threat assessment at the same time. 

Violence ranks as one of the least effective problem-solving tools: it gives rise to more difficulties than it stops.  Some people either don’t learn from experience or don’t learn fast enough, and despite repeated failures, continue to use violence.

Or maybe those people have problems with impulse control.  Maybe most of those have had impulse control weakened by alcohol.

Violent men have distinctive hands.  Look for enlargement and discoloration at the back of the hand, over the joint where the index finger and the middle finger join the hand.  Watch out for scars.

The repeated punching and fist push-ups of martial arts enlarge the same joints and darken the overlying skin, but don’t leave a lot of scars.

Towards the end of a visit, I asked a patient what style of martial arts he does; the tell-tale knuckles had thick, dark calluses.  His eyebrows furrowed. 

I explained the findings: skin changes and joint hypertrophy without scars.  He chuckled.  He loves his work, welding, and the gloves give marginal protection from the heat.  Right-hand dominant, he holds the work with his left.  Thus his non-dominant hand has the most dramatic skin thickening.

Human skin exposed to heat for a long time gives rise to a particular physical finding, recognized so long ago that it carries a Latin name, erythema ab igne, means “redness from fire.”  In this case, the extreme heat and the very long duration has permanently changed not only the color but the thickness of the skin.   

The patient gave permission to include this information in my blog.

The most toxic placebo

July 13, 2022

For the Medrol that comes in a pack

Of requests there are never a lack

If it’s too short or too long

That steroid is wrong

There are better and cheaper.  That’s a fact.

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, traveled and worked in out0of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

I attended 15 patients today, 4 of them children. 

Two people, at opposite ends of the age continuum, came up positive for COVID-19.  Neither had immunizations.  I wrote my second ever Paxlovid prescription.  Looking forward, I trained my Dragon dictation software to recognize the word. 

I sent 4 people for leg ultrasounds to look for blood clots; all 4 came back normal.  One of those patients represents a complete mystery, but despite lack of medical attention and lack of a good diagnosis is getting better. 

Ear concerns brought in 4 others.  None had ear infections.  In one case I recommended getting a digital otoscope for future use.

I ordered x-rays that came up normal.

Two patients came in concerned about sinusitis, one will probably benefit from antibiotics, the other would more likely sustain harm than good from them. 

Three patients in a row had RN degrees.    I found it a relief to speak medicalese with them.

I brought out GoogleImages 8 times.  Mostly I find the pictures educational, but sometimes I get a really good illustration and I can say, “Does that look like your pain?” and at that point the website becomes a diagnostic tool. 

For the sake of confidentiality, I won’t discuss the patient or the malady, but I talked about why I find fewer and fewer reasons to prescribe a Medrol Dosepak, a powerful 10-day course of steroids (also called glucocorticoids, similar to prednisone or cortisone). 

In a different century in a different state, I cared for a 19-year-old.  He had required large doses of steroids 22 months prior.  He got the 1 in 10,000 complication: the top of the top of his thigh bone died.  It ruined his hip and it ruined his life, and during the following two years that I knew him he wrestled with bouts of suicidal depression. 

Ever since I’ve shied away from these powerful drugs.  Without doubt, they are the drug of choice for certain problems, like asthma, bad emphysema, polymyalgia rheumatica and severe (more than 10% body surface area) poison ivy.  In the last 40 years solid research has shown that either the Medrol Dosepak’s 21 pill, 10-day course is too short or too long, or that it constitutes the wrong steroid.  Cheap, generic prednisone can do the same job at less than 1/10th the price. 

The better the research, the thinner the evidence that steroids do any good outside of a very few illnesses

One of my colleagues referred to them as the “most toxic of placebos.”

Medicine changes but the disease doesn’t

July 12, 2022

The kid knew me, no delay

By my toy, he’d seen me play.

It’s distinctive, my yoyo

And the way that I throw, though,

It might be the things that I say.

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, traveled and worked in out0of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

I got permission to write about a couple of patients. 

I make no secret of using my yoyo to establish rapport with my pediatric patients.  Today, I walked into the exam room, and, first thing, set down my yoyo.  The patient, masked, said, “I know you.”  And in fact, I had treated him at another facility in northwest Iowa.  But the last time I worked there, I had a full beard and no mask.  Still, he knew me by my distinctive yoyo. 

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In another century, in a different town, before HIPAA, early in my career, I took call for my group on Christmas.  Late in the evening, I accidentally saved a patient’s life because, during the work-up for Fever of Uknown Origin, the radiologist found a malignancy in its earliest, most curable stage.  I don’t think that patient ever forgave me.

Earlier that same day, as the shadows lengthened, and night fell, I cared, for three young men  successively who turned out to have a disease in common.  I had not seen a case prior, and I have not seen a case since that one day in the 80’s.  But I’m pretty sure I found one today. 

Medicine has changed in the meantime.  Back then I carried two medical references in my white coat pockets.  When the first patient came in through the ER, I pulled the one for adults, the Washington Manual of Medical Therapeutics, generated some ideas, then took the stairs to the Medical Staff Library. I pulled out the latest edition of Harrison’s Textbook of Internal Medicine.  Within a half hour I had the basics down, knew which labs to run (with an eye to practicality to see what would come in soon enough to be useful).  I took the stairs back up to the first patient’s hospital room.

In the 21st century, and especially during a pandemic, we don’t hospitalize patients if they can possibly be taken care of at home.  The labs that would have taken a week to run back then will be back tomorrow; a few won’t result out till Thursday.  I dialogued with the patient as I searched the Internet to see the latest in diagnosis and management. 

Medicine may have changed, but the disease hasn’t.  We don’t know why it happens or why it comes in clusters, but we have good criteria for diagnosis.  The treatment remains the same.

Honey works as well as codeine

June 30, 2022

We can talk of the Paxlovid cures

Or how the cough after COVID endures

No matter the money

Nothing beats honey,

At least, that’s what the research assures.

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, traveled and worked in out0of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

The last time I had COVID I ran a fever for 16 days and lost a kilo (about 2 pounds) ever 3 days.  I didn’t have an appetite, and I slept a lot. 

Maybe Omicron lacks the viciousness of the variant that hit me in November of 2020.  Maybe having had 2 COVID infections and 4 immunizations has empowered me in my personal struggle with this virus.  Maybe Paxlovid is doing its job.  One way or another, the worst part of my symptoms come down to cough and a bitter taste from the meds.

The fact that we have dozens of cough remedies should tell us that none of them work well.  In the absence of wheeze, my old favorite, the albuterol metered dose inhaler (“puffer”) is unlikely to help.  All those preparations whose names end with DM indicating the presence of dextromethorphan, a cousin of morphine, work as well as the ones with codeine.  And all of those work as well as honey, but no better.  So that the old home remedy of tea with lemon and honey turns out to be better tasting than the stuff at the pharmacy, and just as effective (or, if you will, ineffective). 

So when my cough broke up our evening Scrabble game, I reached for the honey. 

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Two days later, I have finished Paxlovid.  The bitter taste is gone.  In accordance with CDC guidelines, I can be back on the job, but I have to wear an N95 mask.  I have a good one, fitted to me and tested. 

No one talks about the facial irritation and the sweat that happens inside the mask.  I have to double my morning shaving time to remove enough hair so that it doesn’t rub and hurt at the end of the day.  Still, it’s good to be back at work and seeing patients.  Between patients I have to duck into an unused exam room to unmask and dictate. 

And if I stop moving, I fall asleep easily.  But I don’t feel fatigued. 

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One of my patients today had a long career in radio.  We talked about doing remotes: broadcasting from outside the studio.  My career in college radio with WYBC only lasted 3 years but it had a profound effect on my communication skills. 

I didn’t mention the darker side of “real” radio.  Two weeks of being paid a regular wage at KADX, I found myself profoundly bored. 

Sick isn’t normal

June 24, 2022

I went to the Iowa Great Lake

Till I sneezed, I coughed, and I ached

Yes, the diagnosis is COVID

Now I’m taking Paxlovid

And Tylenol helped my fever to break.

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, traveled and worked in out0of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

My current position gives me 3-day weeks alternating with 4-day weeks.  

But the pandemic continues, as does the Great Retirement.  A lot of doctors and nurses have left their professions and gone on to other things. 

Thus some of my “4-day” weeks include a Wednesday off, because of nurse staffing shortages.  Yesterday we decided to take in the Iowa Great Lakes, probably the most notable tourist destination in northwest Iowa. 

We took our time.  We started with breakfast on main street, and a prolonged chat with a young woman who travels for a living.  Then we drove north.

We strolled through the Iowa Great Lakes Maritime Museum, preparatory to a walk through the Iowa Rock ‘n’ Roll Hall of Fame. 

At just the right time I didn’t feel well. 

The symptom onset came abrupt and without warning.  Aching, fatigue, malaise, and gut upset came at about the same time and I could feel my temperature start to rise. 

If you see me put my palm to my forehead, I’m checking my temperature, not expressing dismay.

We left Lake Okoboji before lunch.  On the way to the apartment we stopped for a thermometer and a COVID test kit. 

The test came up positive within a minute; I didn’t have to wait for 15. 

I settled down to take my temperature.  Not that the thermometer has more accuracy than my palms’ thermoreceptors, but from experience I knew that if I say “fever” someone is going to ask for a number.

Proper use of a thermometer, whether electronic or mercury, demands keeping it in till it quits going up. 

I notified my clinic manager, certain I’d miss work the rest of the week.  Then I started trying to get a prescription for Paxlovid. 

My calls got shuffled while I melted into the bed.  Tylenol helped the fever and aches, but I kept feeling awful. 

Pharmacies and offices closed and I didn’t hear back while the night darkened. 

Cough, sore throat, runny nose and sneezing kept me from sleeping well.  But as soon as 8:00 AM rolled around I called my doctors’ office and asked, again, for the prescription. 

I made Bethany drive.  We arrived at the pharmacy drive-through just after they opened.  I took the first 3 pills as we pulled away. 

It seems that the Great Resignation includes pharmacists, too.  This town has several pharmacies but even the national chain lets their people out for a lunch break. 

I napped for the next 40 miles, and finally Bethany needed coffee.  By that time the antiviral had kicked in and my appetite had returned. 

Bethany got coffee at McDonald’s.  Not far away I got Potato Oles at Taco John’s. Normally I refuse to eat fast food, but sick isn’t normal.   

Clinical triumphs

June 19, 2022

I’m learning the things not to say

If I want energy at the end of the day,

I fail to judge

Just a question or nudge,

And I engage the children in play

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, traveled and worked in out0of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

Clinical triumphs are what keep me going, but I have a hard time defining them.

Last week in one day I found that 3 of my patients have b12 deficiency, 2 others have marginal B12 levels, and one has folic acid deficiency. 

I love vitamin deficiencies because I get to save the patient’s life for pennies a day using minimal disruption.

Today I had another great day, and this time the triumph came, not from finding the drug abuse problems but from finishing the visit having said what I needed to say to three patient, talked to them honestly about their substance dependency, and stayed their ally after they left. 

“What do you want life to look like for you in 5 years?”  I asked, then I let the patients answer without interrupting.  I let them build their dreams, some more attainable than others.  Most people voice a desire for health, some but not all specify a vehicle or a dwelling or a relationship.  A bit later I get out the calculator and I add up, for a year, the cost of alcohol, tobacco, caffeine, diverted drugs (that is, someone else’s controlled psychoactive medication used recreationally by my patient) and marijuana up  and multiply by 5.  Keeping the screen clearly in the patient’s view, I ask if that amount of money could help make their dreams come true. 

And then I ask, “So how does your pack a day of Marlboros/daily street amphetamine use/fifth per week of vodka/gram a day of marijuana/6 pack a day of soda pop fit in with your dreams for 5 years from now?  And remember, this is your agenda, not mine.”

Then I listen.  I don’t argue, judge or ridicule though I have to urge to do so. 

I could put in the time and the energy because I have a reasonable schedule and fabulous support staff. 

I confess with similar patients in the past I have tried a hard line, attempting to make them see the error of their ways.  Such an approach frustrates me, drains my will, and the patients would probably do better if I didn’t say anything.

Those weren’t the only clinical triumphs, though.  I have to add in the pediatric patients whom I examined without the use of force or coercion.  I played my way through the examination. 

I had a great day.

Ah, spring. Doctors retiring.

June 11, 2022

The docs all want to retire

And there’s no one left you can hire

After we rave and we curse

No mater how big the purse

Here and there the outlook is dire

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, traveled and worked in out0of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  I followed 3 years Community Health Center work with more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

Spring in Iowa means rain, ticks, morel mushrooms and the miracle of sprouting crops. 

My apartment here looks out onto agricultural land.  A smaller parcel holds a couple of horses.  Beyond that, in less than two weeks the corn crop has gone from a faint shade of green against the brown earth to a blaze of emerald. 

Like much of Iowa, the county has had such sporadic rains that some rivers flood less than 20 miles from spots still under a drought designation. 

Temperatures warmed up enough 3 weeks ago that people started getting outside for recreation and now the first athletic injuries have begun bringing in patients.  Most have problems aggravated by work, but few if any will consent to declare a work-related injury. 

The population of this facility maintains a strong work ethic.   A minority of tobacco users, and an even smaller minority of marijuana users.  Whether a person drinks a six-pack a night or a six pack a year, almost everyone regards their use of alcohol as minimal.  Alcohol’s impairment of math skills remains problematic when trying to quantify an individual’s intake.  The vaguer the number, the more likely it is that the patient doesn’t want to remember.  By the time they get to me, though, a lot of bad things have happened from alcohol that haven’t stopped them from continuing to drink. 

In marked contrast to my most recent assignment with the VA, I only attend a scattering of veterans.  Most didn’t realize they could get free hearing aids.  The majority express skepticism when I tell them that the VA has morphed into a warm and caring institution. 

I’m still trying to get back to Canada to work, and because I  do, I get a lot of email.  The country’s medical staffing crisis stands at the verge of a precipice.  Hospitals are closing.  A million British Columbians don’t have a family doc.  Because of the staffing overloads, physicians are burning out and leaving practice, citing many of the complaints that US doctors do: too many hours, too much government regulation, too many non-patient care hassles.  But they’re not complaining about prior authorizations or the other evils of the US medical insurance system. 

And against that backdrop, I still have to fight like hell to try to get a work permit and my license. 

The good news? Canada makes progress on a national licensing system.  Meanwhile, the US continues to advance on the Interstate Medical Licensure Compact, with 28 states firmly in.