Studying on vacation: pro vs. student

November 24, 2016

I over-prepped for the test

My performance was one of my best

The time that I took

Inspecting my book.

On vacation, but I’ve still time to rest.

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Frequently I do physical exams on late adolescents about to go off to college. The exam itself exists only because of bureaucratic dogma and tradition; we have no evidence to show it does any good.  Nonetheless I use the opportunity to give advice.  I’ve had 27 years of formal education, I tell them, listen to what I’ve learned.

Set two alarms. The first one tells you when to get up and get going, the second one tells you when to stop studying and socialize.

Don’t try to get your work done before you get to bed; you’ll learn twice as much if you study when rested.

Think twice about taking that second drink; you’ll be worthless in the morning.

And don’t take your books with you on vacation. You won’t open them, but their presence will ruin your relaxation.

Because I always brought my books with me for winter break, and I never studied.

But this time, headed east for the opening of the Prolonged Feasting Season, I didn’t take my own good advice. I brought with me my Neonatal Resuscitation Program book and my computer, and I faced a deadline.  My certification ran out today, and I needed that certification to continue employment in a number of venues.

Yes, I had prepped about 8 hours last week, but I hadn’t gotten the whole thing done. And today I conscientiously went through the book the second time, and sat down for the online test.  All in all, I put about 12 hours into the course.

I admit I over-studied. I missed 3 questions out of a hundred, and by lunch time I had my certificate.  I have yet to take the hands-on portion of the course.

All those years of school, the hundreds of tests, the tens of thousands of hours of homework, just prepared me for being a doctor. I always have more homework; I always have another test to take.  The stuff in high school and college was just warm up, they gave me the skills I need to do my profession. Because I will never have acquired enough data: when I worked in Pennsylvania I had to learn about Lyme disease and poison ivy; when I worked in western Alaska I had to learn about botulism.

Every year since 1982 I’ve gotten more than 200 hours of Continuing Medical Education, about the equivalent of a college semester.

Yes, this time I brought my homework with me. But I won’t let it ruin my Thanksgiving vacation.  I got the task accomplished and I’m going to relax.  Till Monday.

A straightforward ear infection, and the work up of vasculitis

November 19, 2016

Tell me how can I choose?

The labs will come slowly as news

I won’t be so brash

As to diagnose a rash

That shows as many a bruise. 

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Friday morning arrived and the sweetness of yesterday, with 15 patients before lunch and no computer, lingered.
The first patient of the day, an adult with ear infections, gave me permission to write more than I have. Most people who come to the doc with cold symptoms expect an antibiotic, though studies show a good explanation of why an antibiotic runs more risks than no treatment satisfies the majority. Still the explanation takes more time than writing the prescription.
Current wisdom holds that a physician can justify an antibiotic in the presence of fever, more than 10 days of symptoms, or “second sickening,” where a patient started to improve and then worsens.
I see adults with ear infections so rarely, and I spend so much time gently coaxing patients away from antibiotics, that finding not one, but two bright red ear drums in a single patient gave a great start to the day.

The second patient came in with a rash.  I said, “I write a blog.  I won’t say gender, age, name or diagnosis, but I’d like to write about vasculitis and the steps a doctor has to go through,” and the patient agreed.

When I look at a rash, I want to know if it blanches, that is, loses its color under pressure.  And I want to know if I can feel it.  Tiny bruises, petechiae, that cannot be felt, herald serious disease.  I went to the Internet to find what labs to run.  In the three years since I last saw a case of vasculitis, the work-up has changed, but not much.  I printed off a page, handed it to my nurse, gave her a thousand apologies, and asked her to enter the orders into the Electronic Medical Record.

Then I settled in to read about treatment.  We always like to have a firm diagnosis before we start administering medication, and the firm diagnosis can’t happen until the lab results come back.  A lot of those probably won’t arrive before Thanksgiving.  After that, urgency of treatment depends on symptoms.

It took the nurse as long to enter the long list of lab tests into the computer as it did for me to read the monograph.  I thanked her profusely.

I read the authoritative monograph, and shook my head when it said that 72% of cases of vasculitis will not be conclusively diagnosed.

Last century, at another clinic in another city, a young man came in with a sore throat in the middle of a strep epidemic.  I love a slam-dunk diagnosis I can do something about, but as I exited the room, he asked, “What’s this rash?  I was just sitting here and I noticed it,”  and he pointed at his ankle.  With outside temps hovering in the negative double digits, he wore no socks.  Those tiny purple bruises on his lower legs prompted an investigation leading to a hospitalization, and uncovered a heartbreaking story of drama, irony, hunger, homelessness, love, betrayal, and chemical dependency.

Some things don’t show up on a lab test.

 

 

 

 

Spanish at the dairy

November 17, 2016

The cows they are many, the workers are few

Spanish is spoken by all of the crew

I just love a caper

With records on paper

The time in the morning just flew.

 

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Yesterday morning my first email asked me if I would mind going to do dairy workplace physicals. I would get two nurses, records would be on paper, and business would be conducted in Spanish. I asked how much I’d have to pay; the clinic manager laughed.

I saw a win-win-win situation.

This morning I checked Googlemaps and put the address into my GPS. I didn’t think anything amiss until she had me turn right at the edge of town.  Which didn’t quite look like what the map had shown.  I followed the electronically feminine voice until she told me I’d arrived at my destination.

I looked around at a plum thicket, some pasture land, and a grain bin. Definitely not a workplace.

The first person I passed, a trapper throwing a muskrat into his truck, shook his head, and gave me some convoluted directions. As I made the first indicated turn, I hailed another driver approaching.  He got out of his pick up when I asked directions.  He shook his head, too, and then he laughed, and asked me if I’d used a GPS.  I had to admit I had.  Such electronics, he said, don’t work on country roads, and he’d seen plenty of others, including semi drivers delivering goods, make the same mistake.  From his economy of delivery, I could tell the directions he gave had been given dozens of times before.

Three miles later, I got onto pavement, then back onto a dirt road, and arrived at the dairy.

The two nurses preceded me. Halfway through set up, we discovered we didn’t have disposable paper to cover the conference table to turn it into an exam table and we had to phone for a roll.  But I ran through the questions with the first patient, and started the exam.

The learning curve lasted 3 patients, then we fell into a rhythm.

Eighty percent of the physical abnormalities occurred in the head and neck, several serious enough to require follow-up. Not surprisingly, like most American patient populations, I dispensed a lot of advice on binge drinking, tobacco cessation, and dietary restraint.  But every dairy worker gets an enormous amount of exercise, and I didn’t tell anyone to get more.

About half the people came from Guatemala, half from Mexico. We had a good time talking about Mexican cooking.

I learned that the dairy milks more than 3,000 cows twice daily and that the milk gets hauled less than two hours.

When I asked what work they’d done before coming to Iowa, I got surprises. At least two (who gave me permission to write this) finished veterinary school in Mexico.  I didn’t understand what they told me about licensing (after all, I’m 20 months into trying to get a Canada license and I couldn’t explain what I’d learned in less than an hour), but I found out that the three most common diseases they see are pneumonia, mastitis, and laminitis, a problem with the hooves.  Others had university degrees in other areas of expertise, and all wanted to learn English.

I recommended Rosetta Stone.

We finished 15 complete physicals by noon. I lunched at the restaurant the workers recommended.

I make better enchiladas.

 

Gaining fluency in the new EMR

November 16, 2016

This EMR I’ve started to learn

I’m done when it’s time to adjourn

But it’s too many clicks

To get meds to the sick

When others are waiting their turn.

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

After a week on the job here I find myself waltzing through the Electronic Medical Record (EMR) system with fluency I didn’t expect last Wednesday.

This EMR has the advantage that signing back in normally takes 4 digits, the equivalent of a day key on a safe. While pretty robust, today it locked up twice and towards the end of the day the all-important diagnostic search function stopped working.  Thus I had to restart my computer 3 times.

I have to pass through 9 data fields to send a prescription. Finding the right ICD-10 diagnostic code requires passage through the ICD-9 codes, obsolete for two years.

Still, I can free text the heart of my note. I have to click through dozens of fields for the physical exam, but it gives me good choices.  For example, I can click that the patient smells of cigarette smoke.

Allergies and allergy-like problems dominated the clinical landscape. The constellation of itchy, watery eyes with itchy, watery nose and sneezes coming in multiple strings helps distinguish problems originating with pollen or harvest dust from those related to viruses.  When cetirizine went over the counter at the end of the last century, I bid my summer allergy business goodbye and good riddance.  Somehow, the patient population here hasn’t gotten the message that drug and Flonase can be purchased without a prescription.

But we’re also seeing a good amount of urticaria, sometimes called hives: welts like mosquito bites all over accompanied by intolerable itch. I first turn to antihistamines, but for those few who don’t respond I prescribe a short course of prednisone.

Other patients with respiratory issues for the most part suffer from a combination of viral infection and tobacco smoke. I spend a lot of time explaining that in most cases antibiotics cause more problems than they solve.

About a quarter of the patients have a serious problem that requires experience, knowledge and research to diagnose. Sometimes a result will come back abnormal, and when I call the patient I say, “Just because you can see a bear out there with your livestock doesn’t mean you don’t have to worry about wolves.  So I’ll treat what I’ve diagnosed but if I don’t cure you we have to re-evaluate.”

I attend patients of all ages, from infants to nonagenarians. I took care of two Hispanic monolinguals last week and greatly enjoyed using my Spanish.  When an English speaker struggles with a medical term, I’ll  pronounce it, then immediately say, “I speak a little Chinese, too.”

Strep: to treat or not to treat

November 15, 2016

You might have a pain in your throat

There are a lot of folks in that boat

The very next step

Might be testing for strep

But the score will help with the vote.
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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

The day after Thanksgiving 1997 I hit my personal record for patients seen in a regular clinic day, 63. In other contexts, for example taking call, I’ve attended more, but never in a 9:00AM-Noon, 1:00PM 4:30PM office day.
And not one of those 63 had an appointment when the switchboard opened at 8:30AM.
That November day came in the perfect storm context of coinciding influenza and strep epidemics.
I loved strep epidemics. A simple, curable problem where a minute of history, a minute of physical, a minute of warmth, a minute of education, a simple lab test and a shot of penicillin can relieve great suffering.
We treat strep throat to make the patient feel better, but more importantly, we tell ourselves, to prevent the complications of strep throat: rheumatic heart disease and post-streptococcal glomerulonephritis (kidney failure that follows a strep infection anywhere in the body).
When I started residency, we swabbed every sore throat and sent the culture to a program set up by the family who lost a member to rheumatic heart disease, brought on by strep throat.
In ’85 a widely read article questioned continuing strep treatment in an era of declining rheumatic heart disease.  Much discussion followed, the majority opinion holding that the strains of strep responsible for rheumatic heart disease would start to circulate again. Which, thankfully, has not come to pass.  I heard one doc assert there hadn’t been a single case in the US last year, but couldn’t quote a source.

For decades we’ve had rapid strep tests, which remain in common practice, but in the last year the Centor score, now validated statistically, threatens to make the test obsolete.  The patient gets a point for fever, enlarged nodes in the neck, pus on the tonsils, lack of cough, and/or for age between 3 and 14.  Patients who score 4 or 5 should have antibiotic treatment; under 3 should not.

Those over 44 lose a point; but run a very low risk of rheumatic heart disease.  Treatment in that age group only shortens illness by, on average, 18 hours.

And the post-strep kidney failure?  Treatment does absolutely no good.

But I saw a patient, whose parents gave me permission to write that I’d come up with a perfect score of 5.

I gave penicillin with a clean conscience.

When low scorers come in with sore throats, I discourage testing because a positive result would most likely indicate colonization, where the germs live in the throat without causing problems, rather than infection.

I still do testing if the patient requests penicillin injection, and no injection follows if the test comes up negative.  And I’ll continue the practice till further research demonstrates a reason not to.

Most of the patients with strep throat I saw last week had a sandpaper rash, and very few knew it.

Some things you only find by touching the patient.

 

 

Live like a student now, or live like a student forever.

November 7, 2016

Here’s a puzzle for the bold and the clever

If a dollar’s a lot like a lever

You can be foolish or prudent

To live like a student

For now, or even forever.

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  After a moose hunt in Canada, I am back on the job in western Iowa.  Any identifiable patient information has been included with permission.

I didn’t get into this business for the money, and I have a strong aversion to debt. I stayed hungry in medical school till I got a National Health Service Corps scholarship: the Feds paid for my tuition and books and sent me a monthly stipend which paid rent and groceries, but not enough for a car.  In return, I promised to work at a designated Medically Underserved Area, a year for a year.  As I had all along intended to work in the Indian Health Service, I mistakenly didn’t view the contract as debt acquisition.  I savor the memory of my IHS days, but I would recommend that course now only with cautions.

Because debt is debt. Our daughter’s med school financial counselor advised her that she could “live like a student now, or live like a student forever.”

Lending institutions then and now approach medical students with loan offers. On a corporate basis, the payoff works well.  Students can borrow money against the future high earnings.  The lenders’ pitch goes something like “Hey, you’re going to make so much money in the future, why suffer through years of poverty?”

Those students who take the bait for 4 years can acquire debts that last for decades. Some get locked into suboptimal job situations.  And some keep borrowing, maintaining a high-dollar lifestyle but without building wealth.

A banker once told me a lot of doctors have a smaller net worth than their monthly Adjusted Gross Income.

Between keeping a simple lifestyle and Bethany’s wise management of our funds, I can afford now to work as much as I want, and keep visiting new places. For the next few weeks we’ll be in western Iowa.

We have a snug apartment attached to an ancillary service building, and we share kitchen and living room space with a medical and a pharmacy student. The building even carries a sign that says ”STUDENT HOUSING.” And living with students brings back memories of my early career.

I started today learning my 13th Electronic Medical Record system in 25 months.  All have major weaknesses, and this one promises a steeper learning curve than most.  I take no comfort in the fact that Corporate plans to replace it in less than a year.

The community turned out larger, more prosperous and energetic than we anticipated, and the hospital itself appears well-organized and well-run. The primary care area’s layout minimizes the time wastage inherent in larger medical operations.

And, for the time being, I don’t mind living like a student again.

 

 

 

Uncertainty usually strikes at least twice

November 2, 2016

Only a second was I left perplexed

And then with the changes I flexed

I know what to do

When the plans all fall through

I ask, What shall we do next?

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  Just back from a Canada moose hunt, I’ve worked a couple of days in northern Iowa, and I’m taking a few days off.  Any identifiable patient information has been included with permission.

I have been working on practicing in Canada for 20 months. Six weeks ago I thought I was within 2 months, then 3 weeks ago learned that my case would have to go through immigration because I have no plans to immigrate.  And that their review would take 6 months.

OK, I know how to deal with uncertainty. Bethany and I talked for about 10 minutes, with the unspeakable luxury of discussing, Where shall we go next?

If I had the chance to tell me as a teenager what life would look like 50 years in the future, I would not have believed me saying that such freedom could exist in the real world. We decided on interior Alaska for the winter.  And I decided I wanted to work for the Veterans’ Administration, because they have been so very good to me.

I got on the net, I plugged my headphones into my cell, and I started the process. VA facilities run shorthanded chronically, but the one in Fairbanks no longer works with agencies.  And they are willing to work with me directly.

Over the next couple of days I got emails from several people in the institution with a far warmer and friendlier tone than I expected.

Last week I started the credentialing process. I put in a mere 7 hours, finishing yesterday with a trip to FedEx.

Because I cut the agency out, I’ll have to arrange my own housing and vehicle.

Tonight I talked with a man who specializes in selling cars to seasonal Alaska workers and buying them back when the jobs are done. I’ll wait till things have firmed up till I start contacting real estate agents and other housing mavens.

Yesterday I learned that that my putative Canadian gig had found permanent recruits and wouldn’t need me.

Uncertainty, part of the human condition, runs rampant in the locum tenens business, and struck again in less than a week. Yet from experience I know if something falls through, I generally end up having a better time with my second, third or fourth choice than I would have with my first.

I got out my 3×5 cards and started making notes as I cruised Googlemaps and Wikipedia.

I read stuff to Bethany, and we talked. She doesn’t want to go anywhere reachable only by small plane or snow machine, or that has under 1000 people.  I, in turn, define my professional zone of comfort as less than 2 hours from the nearest surgeon.

We have to have indoor exercise facilities for both of us, internet access, and at least one grocery store. Nice options would include a cinema, indoor archery range, and recreational fishing.  I would like to walk to work, and Bethany would like to be able to get work as a teacher.

We’re looking forward to the next adventure.

 

 

Chinese moose parfait

October 27, 2016

I said to my friend, “Make me, please,

Some dishes with moose, but Chinese

The meat from the shoulder,

And a flavor much bolder

With mushrooms, or orange, or snow peas

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 three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Twenty years ago when I took my bow to Alberta after moose for the first time, the road trip became the highlight of the odyssey.  With enough time to avoid rushing, we found Chinese restaurants attached to every tiny gas station.  I found that “almond chicken” can mean a lot of things, and a person eating their way across Canada can order that one dish and never have the same thing twice.

I like Chinese food, a lot, ever since childhood.  When we lived in New Mexico we tried to eat at every Chinese restaurant in Albuquerque, but in 3 years we only managed to hit 17 out of 23.  At a more prosperous stage in my career, I managed to eat at every Chinese restaurant in Barrow, Dillingham, Nome, and Petersburg in Alaska.

I had the best sesame chicken of my life in Grundy Center, Iowa.  I ate my most memorable chicken foo young overlooking the Arctic Ocean in Barrow, Alaska

Karma being karma, what goes around comes around.  At one point during my 23 years in private practice I could count as patients half the Chinese restaurant owners in town.  I learned much about the business, but I would have liked to have learned more.   For example, the wait staff has to learn Spanish because the cuisine is so popular with the Mexicans and Guatemalans.

Time has moved on, those owners no longer come to me for medical care, but I count a number as friends.  And I asked a friend a favor.  Could you, I asked, take this 4 pound frozen hunk of moose chuck (if you really want to know, the subscapularis, part of the shoulder), and turn it into Szechuan moose, Mongolian moose, orange moose, snow pea moose, and mushroom moose?

He smiled.  For you, yes.

On other occasions, other Chinese restaurant owners have made me deer curry, or other ethnic dishes having nothing to do with mainland China and everything to do with the large Chinese diaspora around the Pacific Rim.  Actually, what we conceive of as Chinese food here in the US has little to do with what Chinese people eat, and those venison dishes gave me a startling culinary glimpse into a world of ethnic cooking at whose dimensions I can only wonder.

This time my selections came from the menu.  And they were fabulous.

This moose tastes like very good, very lean, very tender beef.  And the sauces brought out the best in the meat.

Our daughter, Aliya, used the fried rice and leftovers to make a Chinese moose parfait.  Which I have never had before.

Now I have to figure out a suitable gift for my friend.

An encounter with a fellow wordsmith

October 26, 2016

A lexicon connoisseur’s a nerd

The electoral choices absurd

But I went out to vote

And met someone to note,

A fellow smither of words.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Bethany and I went to vote early, as my work will take us out of town on Election Day.

No one I know, conservative or liberal, likes the presidential choices. I have made jokes about needing to take Zofran (a powerful anti-vomiting drug) before casting my ballot.

Though late in the season, construction still dominates Downtown, with the Courthouse parking blocked off by heavy equipment.

Two deputies manned the metal detector and access to the polling place. They found and held the discreet 1- inch pocket knife on my key chain.  I didn’t give them a hard time, though I thought such a precaution silly.

With one exception, I didn’t like any of the choices on the ballot. But I found the name of a former patient, someone I know to have personal integrity and strength of character, and I blackened that circle with sincerity.

When I turned in my ballot, I looked at the desk in front of the poll watcher.

“It’s not very often you see print dictionaries, anymore,” I said.

I like dictionaries. I have a lot of them, more than a dozen, some better than others.  The elite, the Oxford English Dictionary, stands as a paragon of scholarship but even the microprinted edition weighs 25 pounds.  I will use it, if allowed, in a knock-down, drag-out Scrabble or Boggle game, though the people who have played with me bar such reference material.   If someone wants to play a word game with me and specifies a dictionary, I check it for two words.

A zarf is a cup holder; silver in ancient Persia, and plastic in Mr. Coffee installations. The f word, arguably the harshest verb and most overused pragmatic particle in our language, sits as a glaring black mark on our linguistic landscape.  If I use a dictionary, I want it to have a bigger and more honest vocabulary than I do.  If it lacks those two words, I do not recognize its validity.

I didn’t check her dictionary. But I asked if she needed it for her poll registration work.

No, she said, she’s writing a poem. She has a lot of dictionaries, including rhyming dictionaries and thesauri.

I told her I write limericks, and she looked impressed. I’ve written so many by now, I told her, that sometimes I speak in limericks.  And I asserted that limericks don’t qualify as poetry.  I didn’t mention that I’ve developed a rhyming algorithm so that I don’t use a dictionary to help me.

Poetry, the language of indirection, says something by saying something else. Limericks exist for wit and involve cleverness rather than real word artistry.  In a hurry, I can produce a limerick in less than a minute, and I never need more than five.  A good poem, however, will take me at least an hour and involve physical sweat.

But we had a lively discussion on wordsmithing, and what it means to be a writer. I invited her to read my blog, and asked her permission to write about the conversation.

In the end I told her I show kindness to my readers: I keep my posts to about 500 words, I treat modifiers with an ax, and I eschew the passive voice.

And she understood me.

Apology and an abnormal thyroid

October 25, 2016

A veteran I might legally be

Does it feel like that?  Not to me

I sure owe a debt

To the Viet Nam vet

Without any PTSD  

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

I cleared out most of the month to take some holidays, but I accepted a couple of days’ work in a rural clinic not far from home.

I didn’t get formal training on the Electronic Medical Record. It turned out it didn’t take much to get me going.  They let me dictate my notes and they let me work with a nurse who knows her way around.  It doesn’t hurt that I’ve learned 12 new systems in the last 24 months.

I made that observation to a colleague involved in the residency, who noted that our Family Practice residents have to deal with 7 different systems.

The first day I worked in the new venue, I massaged away the headaches of two patients, and helped two others by taking out ear wax. In the evening, I saw three patients in the ER, two of whom required hospitalization and consultation the next day.

The pace of work went well that next day, and I drove home in a reasonable time frame.

Bethany came with me when I returned at the end of last week, driving past corn and soybean fields in the early stages of harvest.

Doctors can take some pretty rough verbal treatment, and an apology first thing in the morning made my day.

I did several pre-op evaluations. In one case, my findings came so markedly unexpected I had to call the surgeon to formulate a plan.

I cared for a Viet Nam combat vet with no Post Traumatic Stress Disorder. I told him how highly I regard the VA.  I see him as a Real Veteran but I don’t see myself that way.  He reassured me that anyone who has to put up with owning a uniform, and having a rank in a system with bad pay and bad management  qualifies as a Real Veteran.  We had a good discussion about emotional resilience and how it plays a big factor in PTSD.  He gave me permission to write about more than I have.

Even if I can’t write about people, I can write about medical conditions. I really like finding abnormal thyroid results.  Because a thyroid gland, either over- or under-active, can cause a lot of different symptoms.  When my thyroid went into overdrive, I could not sleep, I lost weight, I had no inner peace, and I couldn’t sit still.  I know that, sooner or later, my thyroid will quit working and I’ll need to take replacements.  And at the end of the day, the nurse handed me a slip of paper with an abnormal thyroid result, which explained a lot but not all of the patient’s symptoms.