Vancouver Work Permit Pickup

August 19, 2019

I need a permit for work.

I struggle against being a jerk

A reasonable fate

Is a reasonable wait.

I’ll try to make friendly my quirk

 

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I have found my way back to British Columbia.

At 2:00PM I walk into the Immigration section of the Vancouver airport, for the 4th time since 2017.  The layout has changed a little, and today I waited in line just to get in the room, chatting with a young woman from the Czech Republic.

The youthful Canadian Immigration Services officer wears a Glock and Kevlar.  I hand her my passport and a thick stack of papers: LMIA, job offer, proof of qualification, police statement, physical exam, etc., etc., etc.  She looks at them briefly, and hands me a tab with the number 757, points to the almost empty half of the room and politely tells me to wait over there till my number is called.

I wait and I read as I sit close to a bank of 4 other Immigration Services officers, working full tilt with computers and phones.  Pretty soon one calls number 342.

Thirty minutes later another officer calls 343.  I look at my tab and do some arithmetic and decide at this rate, if the officers work 24 hours a day, I’ll get my work permit in 8.6 days.  I expect my papers to take not minutes, but hours or a day, certainly not days.

At 4:00PM I look up from my book with alarm and realize all the officers have left.  When a straggler passes at 4:10PM, I politely express concern that my plane leaves in an hour, and it’s only fair to inform WestJet.

In the US, I must confess I would have been more urgent and abrupt, perhaps even sarcastic.  In fact, back home I would not have walked away from my passport so blithely.  But Canadian society qualifies as more polite and friendly than the US and I don’t want to slip into the stereotype of the loud, brash, demanding American.

With casual friendliness he goes through a door I can’t and returns with the news that my papers are being processed.  Ten minutes later, I get my work permit.

I land in Prince George in the late afternoon, the air cool and wet with a gentle rain.  While waiting for my luggage I rent my car.  The young man looks at my driver’s license and says, “Iowa.  What country is that?”  Of course I say the US, but I don’t admit that most Americans don’t know the difference between Iowa and Idaho, and certainly don’t know the location of either.  I ask if he’s from Vancouver, but, no, he’s from Prince George.

With weather and mechanical delays, I have to wait 4 hours for Bethany’s arrival.  I check into the hotel, have Tibetan dumplings at a restaurant across the street, and watch TV movies on a large flat screen till almost midnight.

At the airport, I make friendly small talk till Bethany’s plane comes in, and then I can not help but jump to my feet, smiling.

 

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Pulling a Sherlock Holmes at a Motel

August 16, 2019

You know, I said to the clerk,

I hope I’m not being a jerk

It seems like a trifle

To guess your cartridge or rifle

I’d say, for you, shooting’s a perk.

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, South Central Alaska.  After two weeks vacation and 5 weeks as a hospitalist in my home town, I am on my way back to British Columbia

Checking out of a motel in Boise, Idaho, I decided to do my best imitation of Sherlock Holmes and I addressed the clerk.  “I’ve been reading Arther Conan Doyle lately,” I said, “And I’d like to make a guess, if you don’t mind.”  He nodded.  “Are you a recreational shooter?”

I find a really nuanced double-take much more satisfying than a heavy-handed startle or exaggerated head shake.  It’s the same kind of double-take that I get when I speak Spanish to a patient who doesn’t expect it.  And this time, I got a good one.  Of course he asked me how I knew.

I admitted I didn’t know, that I guessed.  And I based the guess on a well-healed, subtle, curved scar on the forehead.  Shooters call them a lot of things, including the ought-six hickey and the Leupold laceration; but he referred to it as a scope check.

As it turned out that scar came from a different sport that he didn’t name.  He’d gotten scope-checked before, he said, on the other side.

That’s where Sherlock Holmes went wrong, I replied.  He got hung up on cause and effect: OK as far as it goes but fails to take into account a larger pattern, and I related a different case.

At another time, in another state, an African American came in for his executive physical, and I spotted a distinctive flat, ovoid scar on the shoulder.   I asked if he did a lot of bicycling, and, indeed, he had.  And he wanted to know why I would guess that; at the time he did not fit the demographic.

As it turned out he had gotten his scar at his other favorite sport, tennis.

And then I explained to the clerk about the Calvary Cross tattoo as an indicator of incarceration, though the person almost never gets that tattoo while behind bars.

I also gave out my blog address, and asked for, and received, permission to write about our conversation.

I gave into a hunch and guessed, correctly, his favorite caliber: the .308.  I based my guess on patterns observed in other.308 shooters.  Later, if asked, I would have said that his athletic build and his age tipped me off, but, really, I have gotten good at guessing.

On my way to my car, though, I went one step further.  His bolt action rifle, I decided, comes from either Remington or Savage.  But I didn’t turn around to ask.

 

5 Weeks of Hospital Ended

August 12, 2019

I turned and returned the page

These words are wise and they’re sage

Slow elevators? No glares

I went up and down stairs

It’s the chaos, it can’t be  my age.

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. After 3 years’ Community Health Center work I returned  traveling and adventures in temporary medical positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  After 2 weeks’ vacation and a wedding, I just finished a 5-week stint in hospital medicine in my home town.

Forty-eight hours after I finished my most recent assignment, I sat down to lunch with a friend.

“So, what did you learn?” he asked.

I learned a lot.

By exhausting my vocabularies in Greek, Hochungra, Umaha, and Lakota, I learned that not only do I still retain random words in other languages but using them can seriously lighten the mood of the room

I learned that not all Dineh languages are the same, and that being friendly in one might be perceived badly in another.

I learned that my version of the law of unintended consequences remains true:  from change comes chaos; the bigger the change the greater the chaos.

I learned that I can handle 13 hours of orderly work a lot easier than 12 hours of chaos, and I can handle 14 hours of order a lot easier than 12 hours of order followed by one hour of chaos.

I learned that taking a break to have dinner with my wife brought an enormous boost to my morale.

I learned that hospital work involves so much walking that losing 3 pounds a day came easily.  Especially if time pressure made me choose stairs over elevators.

I learned that while a generalist among specialists might occasionally look superfluous, finding a couple of cases of B12 deficiency or starting Parkinson’s medication can still make me dance.

I learned that whining about a bad electronic medical record wastes my time and emotional energy, but embracing it and calmness work together.

I learned that if it takes the help desk a half hour to get back to me, I can generally find the solution. Before they call.

But I also learned to give up defective software right when I when I find out it’s defective.  Complaining to someone with a financial interest in a task made impossible by the tools at hand works a lot better than not speaking up.

I learned that a clock in a doctor’s lounge will go for months with a dead battery unless I take it upon myself to fix it.

I learned that everything in the real world, even medical care, carries a degree of geographic imperative.

I learned that staying friendly in the face of internal anger gets me further than expressing that anger.

I learned that despite my insight and learning, I could backslide down the slippery slope of workaholism right to the knife edge of burnout.

I learned that a stressful, chaotic work environment changes me physically, from my gut to my body odor to my rate of hair and nail growth.

I learned that I’m a much better husband if I don’t work 12 hours days 3 in a row.

I learned that a 12-hour day rarely ends at 12 hours.

I learned that mission creep is inevitable.

I learned that nurses who say, “Don’t bring chocolates,” don’t mean it.

I looked at my fork, then at my friend, and I said, “I’m not 65 anymore.”

 

The value of not judging

July 27, 2019

If your logic is flawed I won’t say

And I’ve found at the end of the day

I do far more good

If I avoid, as I should,

Judging others as I go on my way. 

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  After two weeks vacation, I’m working now as a hospitalist in Sioux City.

Even when I’m not at work, I’m still a doctor.

On a Saturday walk I passed a workman using a grinder to remove mortar between blocks in a wall.  Covered with dust, he still had a moment to greet me.  In the silence that followed the grinder’s off switch, we chatted, and I wondered how to approach the idea of safety equipment.

After a while, I pulled out one of my hearing aids.  “I used to work construction,” I said as I held it up.

He said, “I’m 55 and I’ve been doing this since I was 17 and it hasn’t killed me yet.”

I didn’t point out the flaws in his reasoning.  I kept chatting amiably.  When I turned to go he said, “Maybe next time you see me I’ll be wearing earplugs and a mask.”

As I walked on I marveled at the effectiveness of motivational interviewing.  By not lecturing him I got him to think about his decisions.

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As a social gathering the same day I met a young man with a pronounced stammer.  When I could, I maneuvered him away from the crowd.  His stammer eased.  I asked if he’d seen The King’s Speech, a movie having to do with UK’s King George VI’s stuttering problem; he had.  I asked if he’d ever tried propranolol.  He hadn’t.

Originally approved by the FDA for high blood pressure, the first of a class of compounds called beta blockers, I learned about it in medical school.  We have better drugs now for the original indication, but, because it blocks some of adrenaline’s actions and it gets into the brain, we have found uses for it in stage fright, performance anxiety, excessive blushing, excessive sweating, migraine, hyperthyroidism, essential tremor, and premature ejaculation.

But it also works for stuttering.

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I had to drive to Minneapolis for the yearly medical exam required to keep me coming back to Canada.  Waiting for my name to be called for lab work, I sat across from a nice-looking but obviously distressed young woman.

With tears streaming from her eyes and her nose running, I formulated a list of possibilities, or differential diagnosis.  After she yawned a couple of times and shook violently for a few seconds, the most likely possibility came down to acute narcotics withdrawal.  I had no wish to intrude on her privacy, and did not look her in the eyes to check for dilated pupils, and I couldn’t confirm goose pimples through her long sleeves.

She is not my patient.  I do not have a Minnesota license.  But I have gotten past the tendency to judge addicts.  I could read her discomfort in her body language.  And I knew that her backstory would be full of drama, irony, and tragedy.

The start of a new old adventure

July 7, 2019

You know, I said with a smirk

I get along fine with the work

But the record electronic

Is like the old plague bubonic

And did away with the former ward clerk.

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  After two weeks vacation, I’m working now in Sioux City.

A week ago, I stepped back into one of my home town hospitals as a hospitalist.

The United States and Canada remain the only industrialized countries where outpatient doctors regularly do hospital work, but it didn’t used to be that way.

When my father finished his cardiology fellowship and hung out his shingle, hospitals assigned beds to doctors on the basis of seniority; a new doctor would have to ask for a consult to get a patient admitted.  A hospitalist, that is, a physician providing patient care only in the hospital, would have been ranked with the interns and residents; close to unthinkable at the time.

In the early ‘80s, in residency, we got taught that hospital work justified extending the work day because it represented revenue without overhead.

I found out different in private practice.  Drive time robbed the efficiency, and later, so did architectural changes.  In the hour it took to care for 2 patients at two hospitals, I could have attended 4 at the office.

In those days, we talked about the waste of having six docs see 2 patients each at two hospitals, but we didn’t want to give up continuity of care.

Then one summer, I volunteered to take care of my practice’s hospitalized patients at the facility closest to my house.  My partners moved their clinic start time from 9:00 AM to 8:30 AM, I moved mine to 10:00 AM. By the next summer I was rounding on 18 patients, still able to arrive at clinic on time.

I could move fast because I chose the last hospital in town to adopt the electronic medical record (EMR); I could not have kept up that pace except using paper charts.  My Dictaphone handy in my pocket, I dictated while I walked, with a cart for the charts.  Over the course of time I evolved small efficiencies that added up to hours.

I learned a lot.

Later, during my years with Community Health, the crush of a growing inpatient load necessitated giving over our hospital practice, with the exception of newborns, to the newly established hospitalist programs.

Two trends encouraged primary care physicians to leave hospital work.  When the EMR looks like a stick, a hospitalist program looks like a carrot.  And the larger cultural context serves as a push towards increasing specialization.

Most hospitalists work through hospital programs; few practices designate one of their own as a hospitalist.

(In Prince George, British Columbia, the growing trend of new docs keeping their business 100% outpatient without hospital credentials, has given rise to a growing coverage problem.)

I have a temporary position as a hospitalist in Sioux City, the place of my permanent residence. On my first day I saw a lot of faces light up in recognition, staff and patients who remember me from 5 years ago.

But consider the irony: I’m doing the same job I did 9 years ago, but now all at the hospital.

 

 

A visit from my friend of 50 years

July 2, 2019

My friend, on a trip down the road

Made a stop at my humble abode

He’s met the requirement

For his retirement

And there’s wisdom that he has showed.

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  I just finished two weeks vacation.

 

My friend of 50 years, Al Willard, came to visit.

Al and I met freshman year at Yale, and our friendship cemented the summer of 1970.  We shared a house Junior and Senior year.  One Sunday we rode our bicycles the 50 miles from New Haven to New London to visit the Connecticut College for Women.

We planned a bicycle road trip from Connecticut to Colorado after we graduated.    In the process of readying the machines we ignored the news and the weather reports, and pedaled right into the wrath of Hurricane Agnes.

Most of the country remembers that summer for Spassky-Fischer chess and Nixon’s Watergate scandal.

We started badly prepared and (by today’s standards) ill-equipped.  By the time we finished we had learned a good deal about bicycle repair, camping, and friendship.

In 6 weeks of road trip we pedaled 20 days and covered 2100 miles.  That relatively brief window assumed a disproportionately large position in making us who we are.

Three years later, the summer before med school, I completed my coast-to-coast ride when I pedaled a different bicycle out to San Diego to hang out with Al, working on his PhD.

(The same summer, Bethany visited her friends on the 3rd floor of the same building where Al worked on the 4th floor; we would not meet till 1979.)

Over the next ten years I built my medical skill set while Al went from PhD to post-doctoral research to researcher.  We have continued to visit each other every few years.

Two years ago he retired from his last job, the deputy director of National Institute Neurologic Disease and Stroke, with more than a thousand employees and a budget in the billions.

He loves his retirement.  He gets a lot of exercise, he does a lot of brain-intensive games.

He still has his mother and they’re working on her bucket list.  They’ve done New Zealand and Australia.  This summer they’re going to the Calgary Stampede, it will be their literal first rodeo. He helped move her to his sister’s place, empty out the old house, and establish her in the new.  He visits his siblings and his nieces and nephews.

I scheduled nothing during his visit, but the cherry crop came ripe just before he arrived, and we picked, pitted, and jammed.  Bethany made a couple of pies.

I cooked a batch of mole (mo-lay), a spicy Mexican dish with chocolate, tomatoes and chicken.  I honed that recipe during the two years we shared a house.  It brought back memories.

But at the last minute my next gig requested two hours of orientation for the final night of Al’s visit.  I resented it, but I went anyway.

I still have a lot to learn about setting priorities, and even more about retirement.

A wedding in Indiana

June 25, 2019

Here’s to Alfred and to Nicole

Their plan, their life and their goal

Two doctors, a pair

To their joy, is our prayer

It comes from the heart and the soul

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  I plan to take a few weeks’ vacation

Bethany and I have known the Benzonis, both physicians, for decades. Tom staffed ER at one of the hospitals, and we established a good working relationship early on.  Noreen ran a Community Health Center.  Our children played together.

During the winter their daughter, Nicole, asked if I would officiate at her upcoming wedding.

My initial reaction mixed equal parts of honored and surprised.  I come from a Jewish background, the Benzonis Catholic, and the groom, Alfred, Buddhist.

I agreed immediately.

A healthy exchange of emails followed.

I got an online clergy certificate, good for weddings in all states except Pennsylvania and Virginia

Wisdom is where you find it.  Buddhism gave me the best wedding vows.  Jewish nuptial traditions lend a basis for stability, and for great showmanship.

The following comprises most of the wedding, and appears here with the permission of the family.

The heart of any wedding is an agreement, an understanding, or, if you will, a contract between two people.  That contract may be verbal or written, it may be implicit or explicit, it may be according to traditional formulae or it could be composed on the spot.

Change is inevitable.  You cannot cross the same river twice.  You are not the same person you today that were went you went to sleep last night.

Nothing can be understood outside of its context, and the context of the human race is changing faster than it ever has with no signs of slowing.

How, then can two people who will change inside a context of radical change, pledge permanence?

In the face of all cynicism and aridity of the soul, love is as perennial as the grass, a force of the universe as strong as gravity, so powerful that it can bring order out of chaos.

Ketubah is Hebrew for contract, and that contract, that you’ve already signed, is the heart of your wedding.  It seems a good idea then, that any contract should be regularly revisited, and, if need be, revised.  What does this marriage mean to each of you?

Strongly consider renewing or renegotiating the contract on your anniversary, whether it involves something as prosaic as bathtub drains or something as profound as children.  The contract can be as flexible or as rigid as you make it.  But stick to your agreement for its term.  Don’t change the rules except by mutual agreement.  Be forthright in communicating your needs and expectations. Be good to each other; given the choice between doing something nice and something else, choose nice.  Be generous to each other, both giving and receiving.  And be forgiving, for yourself and your partner.

Nicole and Alfred do you pledge to help each other to develop your hearts and minds, cultivating compassion, generosity, ethics, patience, enthusiasm, concentration and wisdom as you age and undergo the various ups and downs of life and to transform them into the path of love, compassion, joy and equanimity?

Alfred and Nicole: “We do.”

Recognizing that the external conditions in life will not always be smooth and that internally your own minds and emotions will sometimes get stuck in negativity, do you pledge to see all these circumstances as a challenge to help you grow, to open your hearts, to accept yourselves, and each other; and to generate compassion for others who are suffering?

Alfred and Nicole: “We do.”

Understanding that just as we are a mystery to ourselves, each other person is also a mystery to us, do you pledge to seek to understand yourselves, each other, and all living beings, to examine your own minds continually and to regard all the mysteries of life with curiosity and joy?

Alfred and Nicole: “We do.”

 Do you pledge to preserve and enrich your affection for each other, and to share it with all beings? To take the loving feelings you have for one another and your vision of each other’s potential and inner beauty as an example and rather than spiraling inwards and becoming self-absorbed, to radiate this love outwards to all beings?

Alfred and Nicole: “We do.”

 

 

 

Bringing Alaska fish to the 500-year flood

June 17, 2019

We flew back to the corn belt

All the way the worry I felt

I’d hoped, I had chosen

To keep the fish frozen

But feared the hundred-pound melt. 

 

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  I plan to take a few weeks vacation

At this time of year, close to the summer solstice, Alaska nights never get really dark.  We left Friday morning in the semi-darkness, and drove to the Kenai airport.  We saw one caribou and no moose on the way.

The day before we’d brought frozen halibut and salmon to one of the many fish processors for packaging with dry ice.  We put most of the fish into 50-pound boxes, and arranged to ship the remainder, about 36 pounds, to our friend Les, in Anchorage, who took us out halibut fishing: https://walkaboutdoc.wordpress.com/2019/06/08/the-biggest-fish-i-caught/

I worried about the fish.  I have had enough summer travel plans drowned by thunderstorms and delayed flights, occasionally arriving 2 or 3 days late.

When we finished having our bags weighed, I identified myself as a physician to one of the ticket counter staff and advised her to get her thyroid checked.  She replied she already knew she had a problem and she intended to restart her medication.

By the time we walked out onto the tarmac the light had brightened enough to show colors.

We go out of our way to sleep poorly the night before a long plane trip so that we sleep on the plane.

The frozen fish stayed at the back of my mind, through Kenai, Anchorage, Seattle, Portland, Omaha, and into Sioux City.

But the worry didn’t keep me from sleeping, as per plan, on the plane.  Somewhere over the Rockies, flying into the night, the sun went down.

Our friend, John, picked us up.  We loaded the luggage and the two pieces with fish into the trunk.

The darkness of the Nebraska night, something we haven’t seen in months, came as a relief to our eyes.

Much of the Midwest has seen record flooding.  When I came back from my first locum tenens trip, in 2010, I found the Interstate closed in Omaha, with Sioux City onramps repurposed as boat ramps.  They called it the 500-year flood.

Now, less than a decade later, we have another 500-year flood. John navigated through the blessed darkness, detouring around closed Interstate highway.  We chatted about our mutual adventures while Bethany sleeps in the back seat.

Finally at home, with the coolers in the basement, I cut through the tape to find the fish still solid frozen.  We dumped it into the freezer, filling it to the gunwales.

We would not have had room for the 36 pounds of fish we sent to Les.

Unsustainability ends in warm poignance.

June 9, 2019

 

In 12 weeks, I saw 53.

I thought, what a great place to be

But who’s keeping score

When you establish rapport

And on weekends, head out to sea

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 Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

Thursday dawned with one patient on the schedule.

In the last 12 weeks I performed a total of 53 outpatient visits.  My busiest day had 6 patients; I had 6 days with no patients at all.

In contrast, while in private practice, the day after Thanksgiving 1994 I saw 63 patients.  (If you must know, strep throat and flu, with one patient having an active heart attack.)

I never spent less than 30 minutes per patient, a few went close to 2 hours.  Ages ranged from 54 to 90.

Few doctors in Alaska’s population centers accept Medicare because the payment schedule doesn’t cover the added expense of dealing with a truculent bureaucracy.  Thus, aside from veterans, the aged have difficulty accessing medical care.  This, the final visit of my assignment, means that the problem has worsened.

Today’s patient came in at 10:00 AM.  Mostly we talked about his medical problems.  Thus I had to ask his agenda.  What do you want to be doing in 5 years?

The patient’s agenda always trumps the doctor’s agenda.   For example, the exercise program won’t work if the patient hates it, and those who love smoking won’t quit.

My patient and I come from the same generation.  We both love fishing and know exercise’s value..  Both love our chosen professions. We both face the inevitable physical need to slow down, and we both wonder what we’ll do with our time without a schedule.

While I want to keep going at least another 16 years, he wants to be done in 5.  He’s already starting to dismantle his infrastructure.

In the end, the 90 minutes I spent with him revealed things needing investigation.  I put orders into the computer, and refilled prescriptions.

But it also gave me time to establish rapport.  By visit wrap up, we found our agendas closer than we’d realized.

I recommended a doc in a close (by Alaska standards) town with whom I worked at one time.

At the end, our handshake held warmth; under other circumstances our friendship would have grown.  It also had the same poignance of finality that has permeated this assignment.

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Low patient flow lacks sustainability.  It doesn’t generate enough income, and inevitably popularity will grow or wane.

But at least 4 alcoholics decided to change, including one past the age of 70, which I’d previously regarded as sobriety’s event horizon.

If I hadn’t had so much face time, I would have missed the basic problem for at least 12 patients.

Five people needed their thyroid doses changed.  I ran a lot of tests that brought reassurance but did not change management. I made one great diagnostic coup.

At least half my patients work or have worked in fishing.  Showing fishing photos on my phone strengthened rapport.

I used my Spanish 4 times.  I exhausted my Japanese, Korean, and Tagalog vocabularies.

Bethany and I had a wonderful time fishing on the weekends.

I walked out the door at 4:00 PM to clear, blue sky, bright sunshine, billowing white clouds and a perfect temp of 18 C (63 F).

I had no celebratory good-bye lunch; no thank-you cards circulated.

But I hadn’t expected any.  I did my job well: I closed down the practice.

 

 

The biggest fish I caught

June 8, 2019

For halibut you use a large bait,

The reward? A fish of large weight

At the end of the line,

The object’s to dine

But you might need a very large plate.

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 Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

We met Les in residency in Wyoming in 1981.  We have been friends since.  After training, he moved to Anchorage.  We reconnected in 2010 when I worked in Barrow.

He arranged for us to fall into the dream Alaska fishing trip of a lifetime.  For a week, we’d wake up, catch our limit of silver salmon, then halibut, followed by lunch.  We found out we love fishing.

Last weekend Bethany and I went fishing again with Les, who towed his boat to Seward.

We arrived when the tourist season that sustains Seward started to blossom.  Tents and RVs of every size filled a dozen campgrounds.  Visitors to the Sea Life Center packed the parking lots.  Traffic along the waterfront crawled.

We visited Seward back in 2010, taking the train from Anchorage with no other thought than tourism.  We saw glaciers, visited the Sea Life Center, and laughed when a sea otter scrambled across the parking lot.

This time, though, we booked a bed and breakfast and we had fishing on the agenda.

A brooding beauty started the day, low dark clouds brushing up against snow-covered peaks.  We crept out of the harbor to speed into Resurrection Bay.

The morning passed futilely trolling for salmon.  In the late morning we shifted locations.

One of Les’s patients, a fishing charter captain, had clued Les to a halibut spot.  (No, I’m not going to divulge the location of this honey hole. Are you kidding?)

We dropped our lines into 200 feet of water, about an hour before the slack at high tide, when the water stops moving and the halibut like to feed.  Les rigged t-shaped leaders with two circular halibut hooks, and a 4-pound weight (unaffectionately called a cannon ball) and baits of herring and squid.

I felt my weight hit bottom, then cranked my reel a dozen times to cut down on by-catch of rock fish.

From the beginning I got a lot of activity, the end of my rod jiggling at intervals, over the course of 15 minutes.  Then nothing.

I cranked my rig up and found the bait gone.  With fresh bait I dropped the ball to the bottom again.

Less activity this time, fewer nibbles for all.  Les slipped his rod into a socket in the gunwale and went for a nap.  My rod went into a socket, too, and I found a way to sit down and face Bethany on the starboard side of the fishing deck, while keeping my hand on the rod, vigilant for thumps.

After about 20 minutes of mild action followed by 10 minutes of none, I cranked the hooks up again to find the bait gone.  I slipped chunks of herring and squid onto the hooks, took the drag off, and let the cannon ball hit bottom  This time, out of sheer perversity, I cranked the reel 13 times and sat down.

The rod tip moved, I let out a bit of line.  More jiggling, more line out.  Then the pole moved violently and consistently, and I started working the reel, telling Bethany, “He’s committed.”

A 4-pound cannon ball comes to the surface reluctantly enough, but a fish who wants to live actively fights.  When cranking didn’t do any good, I stopped till the fish let up fighting, then cranked some more.  Bit by bit, the fish arose from the deep.

My left hand fatigued, and I slipped the rod butt back into the socket.  After a while I had Bethany hold the rod while I reeled with my right hand.  Then I had her reel for a while.

When she fatigued I took the pole back.  For quite a while I cranked, and watched a bit of seaweed crawl up the line to the tip, and slide back down.  I remarked I didn’t think I was making progress.  Bethany looked at the reel and verified slow advancement.

We woke Les, and we all took turns cranking.

Finally a very large shadow showed 10 feet down, and Les went for the shotgun.

If you go after halibut you should go armed.  Les loaded his a single-shot, break-action, short-barreled .410 with 7 ½ bird shot.  I brought the fish alongside, placed my noise-cancelling muffs and stood back, clinging to the pole as the fish struggled.

A splash of water and a loud bang signaled the end of the fish’s life.  Les gaffed him and hauled him out of the water.

I have never caught a fish even close to 62 inches long and 92 pounds, and Les declared no larger fish has every been hauled onto his boat.

The halibut exceeded the length of the well by two feet; Les suspended him from an eyebolt, and constructed a block and tackle from cordage.  To keep the swinging fish from hurting us, he made the tail fast to the deck.

halibut 2019 Seward

Then we went back to fishing.

Bethany brought in a 45 lb halibut that would barely fit in the well, Les brought in a 50-pounder that would fit only with folding.  Bethany caught a benthic rock fish of good size.  When I brought in another, we decided we had enough fish for not one but two days.  Les brought us back to Seward.

Mostly we like to process fish on our own as much for a bonding experience and a time to relive the trip as to save money.  But with close to 150 pounds of fish, Bethany and I decided to pay to have our two fish filleted, vacuum packed, frozen, boxed and shipped.  We gave our rock fish to Les.

With the boat hauled out, we turned our exhausted attention to dinner.  We in fact found a place that avoids the tourist hordes by falsely advertising “Cheap Beer & Lousy Food.”

2019 June cheap beer & lousy food