On marijuana, wages, and education

November 4, 2018

Here’s what to learn from the sages

Education is not just about wages

Your life it makes richer

For the depth of the picture

And it keeps your mind out of cages.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Medical school starts with 2 years of classroom study, with little actual patient care except classes in interviewing and physical exam. Third year brings the cataclysmic change to clinical work: one month you sit in lectures and try to absorb as much as you can, and the next month you deal with people who bleed, vomit, cry, and sometimes die.

My medical school, based in East Lansing, sends 80% of the medical students to smaller communities for those crucial two clinical years. I went to Saginaw.

At the time, the automobile industry dominated the town. Up till then I had always lived either in big cities (not my favorite) or college towns.  Saginaw changed my context radically; I ran into a lot of blue-collar workers on a daily basis.  I had left my bubble.

One of my classmates, having grown up in Michigan, remarked that one of his high school classmates started working in an automotive plant at age 18, and a doctor would have to work till age 45 or 50 to match lifetime earnings.

I recall a millwright on the internal medicine service who made as much money as the attending physician, and worked much better hours.

Fast forward 42 years, and Bethany and I have landed in a different mill town.

Bethany substitute teaches. She found the elementary students polite to the extreme.

But she has concerns about many of the middle and high school students, concerns she shares with the administration. A lot of students don’t engage in class because as soon as they turn 18 they can start high-paying mill jobs.

My grandfather had a talk with me before I went off to college for the first time. A man so wise that even as a truculent 18-year-old I recognized his wisdom, he said, “You don’t get an education to earn more money.  You get an education because an educated man leads a richer life because he understands what he sees.”

Few people have a grandfather like that, and fewer still come from a cultural background that values learning for the sake of learning.

Of the 18 patients I attended on Friday, while the season’s first heavy, wet snow hushed the town, 14 abuse marijuana, using it multiple times daily. Of those, 12 have high-paying factory jobs, and of those, 10 have chaotic homes.

I don’t know where to look for causality, to the weed, the wages, or elsewhere.

But I do not think making marijuana legal will do anything positive to engage the students in school.

 

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Small non-miracles

November 1, 2018

I don’t believe in my aura

At least I don’t any more-a

I can’t tell you why

A bird will fly and not die

When I pick it up from the floor-a

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I took care of a patient today with a physiologically unlikely (but not, as it turned out, impossible) complaint. Before I had the chance to research, and while I kept my skepticism concealed, I established rapport with the patient and, in the process, learned to use a medical instrument I’d never seen before.

When the world started the change to digital, I ran into problems.  I stopped the first digital watch I bought in 1980, and kept stopping them for another 10 years.  After that they didn’t stop so much as the batteries died quickly.

When I came off the Acoma Reservation in 1985, the first electronic cash register I encountered malfunctioned at my approach.  I attributed the stoppage to the inherent fragility of new technology, but the trend continued for another 12 years.

Our youngest daughter ran into the same problems and to this day kills digital watches.

I do not believe people have auras, and thus I find it hard to account for the fact that digital devices used to break down consistently in my presence.

But, to build rapport, I told these stories to my patient, who also stops digital watches.

She has a way with animals, and she catches birds with her hands.

I recounted the time that a bird flew into our picture window, while our children, age 7, 9, and 11 watched.  The bird dropped to the patio, and the kids immediately demanded that I, the doctor, go try to revive the apparently dead bird.  I picked it up, it regained conciousness, and flew away.   The kids showed no surprise.  I tried not to, either.

My patient told me that I’d done the right thing.  A stunned bird righted will generally come to, but if left supine will die.  If your patience wears out before the bird flies, she said, place it upright in a box or other structure that will keep it upright, and most will live to fly.

I hadn’t known that. I asked for, and received permission to put that information in my blog.

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I came to realize that taking call has all the earmarks of an addictive process, and wrote about it in another forum.  Other people, besides doctors, take call.  In the context of symptoms that could be psychological or physiological, I talk to patients about what addictive processes have in common.  This particular patient agreed vigorously.  I printed out my essay and handed it over.

I had call the night before, and it went badly.  I have suffered adverse consequences because of call, and missed time with my family.  Call has made me physically ill.  As the years go on, I spend more and more time recovering from call.

But I keep doing it.

I felt like the biggest hypocrite in northern British Columbia.

Appreciating normal: brain tumors, radiation, and the adolescent idiocy of love

October 29, 2018

We don’t know when our career starts careening

Insight is hard when you’re leaning

So slowly life sours

Working too many hours

Contrast is the essence of meaning.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Yesterday a patient (who gave me permission to use as much of his information as I care to) came in for a refill of his prescription for lamotrigine (trade name, Lamictal).

My wife takes the same drug, and their stories carry a lot of parallels.

Dizziness brought my wife to MRI in the summer of 2016. A message on a Friday contained the diagnosis of glioma.  Until the proper diagnosis of meningioma came on Tuesday, I thought my world would collapse in less than 60 days.  During that critical 96 hours I learned how much I love my wife, and since then I’ve enjoyed the adolescent idiocy of being in love, and secure with the woman I married in 1980.

A year after one radiation treatment, my wife started having headaches preceded by a smell and some music; verapamil didn’t help her but lamotrigine did.

My patient’s tumor involved more radiation treatments, and he takes lamotrigine for similar but not identical reasons. He emerged from his treatments a happier person.

I didn’t tell him how, when my wife talks, I smile and listen so attentively that it unnerves her. I savor those moments of normality.

I didn’t tell him that the delight I have in the companionship of my mate stands in contrast to my years of working 84 hours a week. But that contrast remains the essence of meaning.  My time with her now is sweeter for knowing what I missed, and that knowing comes from a close brush with loss.

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The very next patient also grinned his way through the visit. He gave me permission to quote him: “I found some awesome words in my career path. Words like floor, walls, roof, and the best one, heat.  And an open and closed sign, that’s another good one, too.”  He had worked for 11 years without those things.

But I didn’t ask permission to discuss his career changes. Doctors are not the only ones who have trouble setting boundaries, and we’re not the only ones who decide to come in from the cold, whether literal or figurative.

Livers and lotteries

October 26, 2018

You could be a taker or giver
There’s a chance, but only a sliver
You probably won’t pick it
So don’t buy a ticket
Thus to keep a healthier liver.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time. Any identifiable patient information has been included with permission.
Abnormal liver tests dominated yesterday’s clinic. Each patient had a different problem, and each went into a different management plan.
The most common liver poisoner, of course, is alcohol. But if a patient credibly claims alcohol avoidance, I have to look for other exposure to alcohol or other organic solvents. I have found a disturbing number of people with medical problems from breathing vapors of Lysol Spray, a product containing 95% alcohol. (Regretfully, many years ago I took care of a patient who later died from liver cirrhosis caused by drinking Lysol Spray.)
Too much food can damage the liver, just like too much alcohol. When rich food has, in the whole of human history, never been so cheap or convenient, NASH, (non-alcoholic steatohepatitis) now ranks second to alcohol for damaging livers. Within the last ten years one of my patients died of cirrhosis caused by overeating.
I still check for hepatitis A, B, and C though a result from those tests hasn’t surprised me for years.
About 1 in 50 people carry the mutation for hemochromatosis, where a person’s DNA fails to code for a signal to quit absorbing iron after having enough. The excess iron ends up in the liver.
Much as a person born with the mutation for continuing iron accumulation after storage reaches saturation, some people don’t know when they’ve had enough alcohol, or food. And some don’t know when they have enough money.
To be rich you must be content with what you have, and, really, without the capacity for contentment a person will always have the drive to acquire more even when not needed.
Even contentment does not suffice to make a person rich. I have met retirees with pensions who have no interest in acquiring more, but they get into trouble precisely because they have enough to keep them from want but they have nothing to do with their time.
The day dominated by liver patients started with news from the US about a lottery jackpot of more than a billion dollars.
At breakfast Bethany and I remarked on the sum, and I said that a pot that large might tempt me to buy a ticket.
Lotteries ruin lives. Losers spend money they can’t afford and find in their losses an excuse to not be happy. Winners gain weight, get divorced, lose their moral compass and see their loved ones die.
So I don’t buy lottery tickets for fear I might win.
But a billion dollars? I could blow it building a medical school to my vision: Hire the most gifted teachers to generate cognitive content for premed and the 2 classroom years, and post online courses at very low cost. Weed excess students by requiring fluency in a second language. Anyone passing Part I of the Boards could apply for a clinical position.
Or, alternatively, I could just keep doing what makes me happy.
And I don’t even have to buy a ticket to do it.

Students playing with slit lamps

October 25, 2018

It’s as simple a one as you’ll find
And I hope that your teacher is kind
Concerning the eye,
Here’s the how, not the why
And playing beats the old grind

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time. Any identifiable patient information has been included with permission.

Most doctors who take call have superstitions. We talk about not using the “q” word (quiet); to do so seems to bring disaster in the form of swarms of sick patients.

Personally, I will not answer a question about how call is going till I can do so in the past tense; I always say, “Ask me Monday.”

I can now say that call went well. I had the great pleasure of having 3 med students.

I asked the students to gather at the ER at 8:00AM, expecting a patient who didn’t show. With no clinical load, and no time pressure, I introduced them to the slit lamp at 8:30AM.

A slit lamp is, essentially, a stereoscopic microscope for examining live eyes in real-time. In larger centers, with ophthalmology (eye specialist) back up, the generalist has no need to learn to use one.  Because I shy away from those jobs, I have had to learn to use the instruments, and I did so by playing with them.

Slit lamps come in a variety of conformations and complexities; the one we have here appears old, simple and wonderfully functional by comparison to the slick, spiffy ones I’ve used in Alaska.

I showed the students the joy stick that enables a doc to focus on different eye structures, and the switch that changes the light playing on the eye from slit (hence the name) to circle to black light. Then I sat on the patient side of the instrument, put my chin and forehead in the right places, and, one by one, talked the students through the proper use.

Actually, I said, “Take off your glasses and have a play. This is about as simple a slit lamp as you’ll ever find.  We have no time pressure, you have complete support from everyone in the room, and you can’t hurt anybody.  Go for it.”

At the end, 5 minutes of play trumped the half-hour of didactics I didn’t  go into.

After we’d all played with the instrument, they asked when to use the slit lamp. “That,” I said, “Is a much longer talk and is best reserved for your ophthalmology rotation.”

I told stories about grouchy specialists and foreign bodies embedded in corneas. Eventually, I talked about Reiter’s syndrome: inflammation of the eye, urethra, and joints, frequently accompanied by fever and rash.

But I didn’t tell them the whole story about Reiter, a Nazi who did such terrible things in World War II that many in the medical community would like to use the term “reactive arthritis” and make the eponym anachronistic.

We were having too much fun playing with medical instruments.

 

 

Looking for the illness behind the addiction

October 24, 2018

I saw some addicted to meth

I want them to keep up their breath

And not lose their molars

Because some are bipolars

Predisposing to a too-early death

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I dealt with a number of methamphetamine addicts today.

Far too often the medical profession in general and this doctor in particular yield to the temptation to judge substance abusers. Such an exercise in self-indulgence on the part of the physician fails to benefit the patient at the same time it saps the energy of the doctor.  I learned those lessons from a doc 18 years my junior.  I wish I learned it earlier in my career.

Most physicians find it easier to focus on the human being in the substance abuser if we also can find a major psychiatric diagnosis.

People do not decide to acquire the diseases of schizophrenia or bipolar (formerly known as manic-depression); such illnesses come to them gratuitously. And, if they had the choice, almost all the sufferers would choose to be sane.  Society in Canada and the US has failed the mentally ill; in both countries they comprise a disproportionate number of the prison population and the homeless.  All over the world, they face a life expectancy 20 years shorter than average.

Thus, confronted with an addict, I’ve started to ask my touchstone bipolar question: “Have you ever had an episode lasting at least 4 days during which you felt great without drugs, slept less than 4 hours a night, and didn’t miss the sleep?” If I get a blank stare, I ask, “Have you ever felt so good without drugs that you didn’t need to sleep?”  and if I get a positive answer, I ask if it lasted more than 4 days.

All the meth addicts I attended today met the diagnostic criteria for bipolar. Each one came from unique circumstances, had unique considerations, and got a different treatment.

During my 3 years in Community Health I took care of a lot of the mentally ill. I learned that schizophrenia, bipolar, and substance abuse overlap so much that trying to tease them apart for therapeutic purposes comes close to useless hairsplitting.

I hadn’t learned those things during my private practice years because that patient population lacks the resources to access upscale medical offices: for the most part they have no insurance, money, or transportation. Too many of them constitute the homeless and the incarcerated.

So I did my best. I prescribed the patients medication and asked for follow-up.  If they don’t come back, I won’t think less of them, because their illnesses include impaired thinking.  And I won’t think less of myself.

 

Computers increasing chaos: it’s their job

October 23, 2018

Computers that make your work slow
Ignore the proper work flow
Despite lots of cash
Sometimes they crash
Leaving you nowhere to go.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time. Any identifiable patient information has been included with permission.
Yesterday our office manager came to me with the news that the electronic medical record (EMR) system would be offline for my weekend on call. I’ll be able to access the prescription history but not the record of the clinical encounters. I would have to take legible hand-written notes on the yellow ER encounter form.
I vastly prefer keyboarding.
Today I worked walk-ins for the morning. Traffic came light. Mostly I saw the consequences of trying to ignore reality. Though only fewer than 18% of Canadians smoke, smokers constitute 80% of my clinical load. Because smokers tend to drink and drinkers tend to smoke and both tend to use marijuana, the diseases that my patients bring me reflect that magic triad.
After the lunch break I returned to clinic with a crashed EMR. One person’s normal attempt to enter normal data the normal way put in a thousand times more data than the memory could handle, leaving an area the size of France without computer access to health records.
Computers applied to incompletely understood tasks increase, rather than decrease, confusion, thus the introduction of the EMR has literally wrought chaos. Canada, like the US, continues a disconnect between purchasers, users, and generators of computer medical systems. No wonder that the system evokes whispered curses throughout the day.
Fewer here than in the States, though, because the US medical system has allowed administrators, insurers, and data miners to hijack the systems at the cost of physician usability.
Still, work flow has adapted to the computer, and, in its absence, work slowed.
The staffers could use a separate program and data base to print out a patient’s prescriptions for the last year, which helped a lot, as most people came seeking refills.
Between patients, I generated a word processing document, and started typing hasty notes. After I finished with the last patient I went back and neatened things up.
In the end, I had a system I could apply to my ER call. I can take hasty, idiosyncratic handwritten notes, and later return to my keyboard to generate a typed, coherent document, which later can be transferred to the EMR.
I found it a lot simpler to dictate a note in front of the patient. But that was last century.

To “Green Out,” the Cannabis Hyperemesis Syndrome

October 16, 2018

Tomorrow up here they will cede

That battle they have waged against weed

A pot head flat broke

Still has money to toke

And won’t listen to me when I plead

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Tomorrow, Canada will legalize marijuana.

In the week since I returned to Canadian clinical practice, I’ve taken care of 4 patients with cannabis hyperemesis syndrome (CHS).

The active ingredient in marijuana, tetrahydrocannabidiol (or THC) usually suppresses the urge to vomit, but if a person uses too much, that effect gets reversed and the person starts to puke.

I first learned of CHS about 10 years ago. In a town I will not name, a young patient kept coming to the hospital vomiting and dehydrated.  Discharge would follow symptom cessation, after a couple of days.  Three admissions later, the complete gastrointestinal workup completed, one of the person’s parents had gone to the net and educated the entire medical community.  Cutting back from an ounce a day to just half an ounce per day solved the problem.  At the time, the doctors thought CHS a rare problem.

A lot of people use marijuana to excess, and a lot of people vomit.  A vomiting pot smoker doesn’t necessarily get the diagnosis of CHS; a craving for hot showers or baths cinches the diagnosis.  Stopping the drug will cure the disease.

I learned the local street slang for CHS this week, to “green out.” It bothers me that the syndrome has become so common that it now has a place in the language.

Given the choice, I prefer cure to treatment, and stopping the THC will cure the green out. Regretfully, application of capsaicin cream (available without a prescription) will treat the problem without curing it.

Legalizing cannabis will cut down on illegal profits by crime bosses, but those criminals will not go away and they will not turn to legal ventures; they will find other unlawful ways to make money.

Revenues generated from the sales of marijuana will not come close to the economic ruin that the increased use will cause.

I try to tell depressed, anxious people they’re making themselves worse with the drug; I meet with vigorous denial. Which leaves me two tools.

One is educational. I tell my patients that because cannabis long term drives down testosterone levels it leads to Low T, and will impair sexual function.

The other is a question: “How’s that working out for you?”  Because not only does marijuana worsen (not lessen) depression, anxiety, and pain, it ruins functionality.  A pot head’s life deteriorates slowly and steadily.  They lose their house, job, car, and relationships.  They can’t afford rent, food, transportation or a lawyer.

But they find money for weed.

 

 

Permit, license, insurance, and a contract with the Queen

October 7, 2018

I ended up feeling so keen

For three things, together they mean

I no longer lurk,

But I can come out to work

After my contract I sign with the Queen.

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, my 50th High School reunion, and a 4-month assignment in northwest Iowa, I have returned to Canada.  Any identifiable patient information has been included with permission.

Monday morning I strolled over to the clinic, marveling at my first snowfall of the year.

I had submitted my work permit electronically to the College of Physicians and Surgeons of British Columbia (CPSBC), which they required before reactivating my license.

I got my new passwords arranged. I’ve done 18 new electronic medical record (EMR) systems in the last 4 years, and, having been away from this one for the summer, I spent the morning practicing.  Mickey Mouse’s name turns up as an imaginary patient in a surprising number of EMRs, including this one.  I entered the diagnosis of felinophobia (fear of cats), and practiced ordering prescriptions, lab, and x-rays. I strolled around the hospital and greeted staffers.

I checked my email every 15 minutes for a reply from the College.

I walked back to the hotel for lunch and a nap. Still unlicensed, I returned to the facility.

By the end of clinic hours boredom set in. One of my colleagues called the College on my behalf.

Tuesday came as a replay. Clicking the REFRESH button every 15 minutes doesn’t count as exercise, and by noon I had started to ache from inactivity.

And I didn’t have cases to talk to my colleagues about. I missed being one of the cool kids who has stuff to talk about.

In the late afternoon my email lit up with notification of license reactivation, but I also had the chance to talk with the College about the possibility getting full licensure, making it return more flexible and shorter assignments possible.

I get my professional liability insurance through the Canadian Medical Protective Association (CMPA), based in Ottawa, 2 time zones to the East. So I called them at 6:30 Wednesday morning (8:30 their time), and by 6:35AM I had insurance.

At 8:00AM I strode into the clinic, grinning. In front of witnesses I signed my contract with Her Majesty, the Queen of England, and started into work.

I took care of my first patient of my return before the official start of clinic hours. I got permission to write about the problem, Eustachian tube dysfunction: the pressure in the ears which follows a cold or allergies and for which no effective medication exists. (Insurance rarely covers the only effective treatment, the EarPopper, a device that “pops” the ear, and costs over $300).

PTSD, chronic med refills, adult immunizations, and discussion of complicated endocrine investigations should not come to walk-in clinic. But they did.  At about 10:00AM I had a patient with a true urologic emergency, when I was running and hour late.

The day didn’t get less frantic after that, and I missed lunch.

I vastly preferred the action of the jam-packed day to the boredom that preceded it. And, at the end, I had cases to talk about, just like the cool kids.

 

Fall colors, campfire conversaiton, and American Media

October 6, 2018

In the north we sat by the fire

I should have used my warmer attire

If discussions of Trump

Turn you into a grump

Just ignore the news that came prior. 

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 a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, my 50th High School reunion, and a 4-month assignment in northwest Iowa, I have returned to Canada.  Any identifiable patient information has been included with permission

Bethany and I food shopped and lunched in Prince George before setting off on a windy, clear, cool day.  Fall comes a lot earlier here in the North than it does in the Midwest, and the autumn foliage colored our drive with bright reds and yellows.

While I drove we held hands and talked about Where Shall We Go Next.  We rank-ordered our choices as Texas, Alaska, Hawaii, and Canada.  Then, in light traffic, Bethany fell asleep.  When I started to yawn I awakened her to keep me company, and, 15 kilometers later, to drive while I napped.

Coming back here felt like coming back home.   We took note of small changes in the buildings and road on the way.

On arrival we found friendly, familiar faces.  We set up our hotel room (really a 1-bedroom apartment) with what we’d brought and what we’d stashed here when we left in May, then we went for a walk in the blustery wind.

We had done a lot in the last 2 ½ days, except sleep.  We napped but I awakened to text one of the permanent docs of my arrival.  He invited me to his back yard for a campfire.

In retrospect, I should have worn my long underwear.

Eight docs sat around an outdoor wood fireplace.  The conversation wandered from medicine to news and back.  Trump.  Tubal pregnancy.  Lead poisoning.  Kavanaugh.  Soy bean prices.  Major trauma.  Beer.  Ultrasound diagnostic advances.  Ontario’s recent elections.  Construction on the road to Prince George.  My summer.  My tribulations with the College, meaning the College of Physicians and Surgeons of British Columbia (CPSBC).  Everyone’s tribulations with the College.  The 90s.  Teletubbies.  More Trump.  More Kavanaugh.

Our host recalled the time when he went out of his way to ignore news and media for two weeks.  He found, at the end, world politics hadn’t gotten better or worse, but he’d been a lot happier.

Then everyone wondered why, as Canadians, they had become so preoccupied with Trump and Kavanaugh.  So I asked what was new in Canadian politics.  Ontario, as it turns out, elected a mini-Trump.