The root that Mayo missed: whittling down the med list

May 18, 2015

Give bad news sitting down

May 15, 2015

The scientific method applied to a long, failing med list

May 14, 2015

Some of the things I told my patients

May 13, 2015

Canada, rainbow’s end, and pheasant glass

May 12, 2015

In the evening I dove east in the rain
With a rainbow out over the plain
No matter what you’ve been told
At the end, there’s no gold,
But in fall, we just might have grain.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Just back from Nome, Alaska, I’m now in Grundy Center, Iowa.
I drove with the sun at my back, eastwards, from Sioux City towards Grundy Center, across flat farmland dotted with wind turbines. The dramatic clouds in front of me contrasted with the sunshine behind me, clarity against darkness. Bit by bit, a rainbow emerged against the backdrop, first at the north end, then at the south, and finally arched right across the sky.

I could not help but remember our train trip south across New Zealand, between assignments. Seven rainbows graced the skies that rainy day.

I picked New Zealand over Ireland in 2011 because of the medical licensure application. Ireland’s 84-page form brimmed with dense prose, indefinite antecedents and esoteric usage despite nominal English, after a week spent on the first 10 pages I gave it up as a bad bit of work, added it to recycling, and picked up New Zealand’s four-pager, which I completed in an under an hour.

Right now I’m working on a Canadian license. The paperwork so far has been reasonable to the point of unbelievability. In fact, I don’t believe it and I’m waiting for the full weight of bureaucracy to fall across my electronic desktop.

Trish, my recruiter, has guided me with patience and kindness. We mostly talk on her days working at home. In the US, recruiters work for agencies to place physicians where needed; the doc works as an independent contractor. The agency guarantees transportation, professional liability insurance, and housing. I can’t generalize for all Canada, but my recruiter puts doctors together with institutions in need. The professional then negotiates with the employer about rate, insurance, lodging, and transportation. In the end, the Canadian recruiter takes a much smaller piece of the pie. And doctors do their own negotiations.

In the beginning, I had no particular geographic aspirations. I even considered working in Quebec because I speak French (acquired, with Rosetta Stone, last year). Later I realized that the French spelling system with its archaic silent letters would threaten sanity maintenance in a medical environment.

Alberta, Manitoba, and Ontario slipped out of consideration, one by one, for different reasons.
So over the course of the last two months, my recruiter has helped narrow my focus from all of Canada to British Columbia, and I have entered the weird world of international licensure. Each province has its own license authority, just as every state in the Union does, but they have a degree of reciprocity.
Why Canada? Not chasing rainbows. I want to work in the Canadian system, which American doctors love to revile without understanding it. I don’t understand it either; I want to experience it first hand, and write about it. In all fairness, I’ve worked the American system for 33 years and I don’t understand it.

And I have all the rainbows I want, anywhere I go. I came over the crest of a hill, and the north end of the rainbow, always retreating at a fixed distance, shone against the brown and green of the Iowa fields germinating corn in the spring. No pot of gold, no leprechauns, just gleaming yellow, and a moment later, for a thrilling second, the south end of the rainbow popped up out of a gulley.

Then, WHAM, a hen pheasant died on my windshield.

Short lines of communication, unusual prescriptions, and vitamin B12 deficiency

May 6, 2015

First day on the job in Grundy Center

May 6, 2015

Finding work and meeting ex-patients

April 17, 2015

The hardware she helped me select

Then noted a pain in her neck

I derived such enjoyment

At her place of employment

No charge for a three-minute check

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 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) I can get along with. I just got back from a 3 month stint in Nome, Alaska.

I returned from Nome to Sioux City ten days ago; Testing my immediate employability theory, I woke up Monday morning with nothing on my schedule, and tried to have work by Wednesday. My time frame incorrect, in less than a week I had work lined up from the 3rd week in April until the last of September.

I don’t write in detail about these jobs until I sign contracts, sometimes not until I see plane tickets. Five out of 6 jobs fall through. This summer I’ll work Urgent Care in 12 hour shifts, from 3 to 5 days per week. And, if things go according to plan, much of my summer I’ll spend working in Pittsburgh.

I’m also talking with a Canadian recruiter. Most American docs reflexively vilify the Canadian single-payer system but few understand it. I want first-hand experience despite the fact that with one exception, every Canadian physician I’ve met hated their system.

But every day I see former patients.

At the gym, a fit-looking, slim, middle-aged woman came up to me while I sweated on the elliptical. “You saved my life,” she said, “It was eleven years ago I stopped smoking. I fist-bumped with her, genuinely glad she changed her life. Yet I believe that if my patient gets better, 80% of the credit goes to my patient, and 20% to me.

Last week at Sam’s Club, a young man approached me with the good news that he’d stopped drinking soda pop and had started drinking more water. He looked healthy.

Yesterday a former patient reminded me that 25 years ago to the day I ushered her into the world. I had the great good fortune to diagnose pregnancy, do the prenatal care, attend the delivery, and perform the well child exams. She has grown into a strong, competent, attractive young woman with an impressive array of skill sets. An asset to the city, her family, and the health care industry, I feel privileged to have watched the process.

Today at the hardware store, a staffer complained to her co-worker about knots in her neck. (She gave me permission to write this.) “I’m a doctor,” I announced, “and I can make those knots go away.” I sat her on a stool at the back of the store and put my hands onto her shoulders, finding the usual set of painful lumps, starting with the upper inside corner of the left shoulder blade, the cluster of four between the shoulder blades, along with the characteristic tightness along the back of the neck. I used a routine that I developed over the years, progressively massaging the head’s support muscles, finishing with a standing upper back crunch. She thanked me profusely.

At the end, I said, “Making your neck knots go away, that took three minutes and it’s free, but it doesn’t address the whole question of why you’re not sleeping well, which is the root cause of the problem and would take 20 minutes.” She wanted to know where I work, and I had to tell her I’m between jobs.

I didn’t tell her I so enjoy making people feel better that I quit charging for spinal manipulation. But I left my business card, and encouraged her to read my blog.

Foxes, itches, triumph, and hunter: on the cusp of leaving Nome

April 1, 2015

On the med list I’m pulling a switch
‘Cause my patient came down with an itch
Now they’re getting the sleep
That’s restful and deep
And for trazodone I found the right niche

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) I can get along with. Right now I’m back to Nome from temporary detail to Brevig Mission.

I took care of a patient with a very bad diagnosis and a very bad itch. I will leave it up to the specialists to try to change the course of the disease, here in Nome I will try to relieve suffering. Because itch in the context of unrelenting pain constitutes torture. We looked over the med list.

Me: Aren’t you allergic to codeine?

Patient: Yes, it makes me itch, real bad. Same with the hydrocodone.

Me: Stop picking at yourself. Why do you take the oxycodone?

Patient: Beats me. Doesn’t work. That’s why I finished ’em early.

Me: If they don’t work, why do you take it?

Patient:

Me: Maybe oxycodone is making you itch. Let’s try stopping it.

Patient: But how am I going to sleep?

Me: How are you sleeping now?

Patient: I’m not. Those pills don’t work.

Me: Maybe we should stop them.

Patient:

Me: How about if I give you a sleeping pill to help you sleep and you come back next week. How about trazodone?

It took some explaining, but the patient came in, looking fresh and happy and focusing a lot better, having slept well 4 nights in a row, and now having much less pain. Because (everyone knows) that good sleep helps a person deal with pain.

And another demonstration of the principle of ABCD (Always Blame the Cottonpickin’ Drug).

***

I can post this about the young man because I got permission from him and his mother and because everything is on Facebook. Well on the way to being a hunting legend at age 14, he got his first polar bear at age 11, same year he got his first bowhead whale. He has lost track of the number of walruses he’s gotten so far this year. I still won’t publish his name or what he came in for.

***

I stepped into my cubicle about 10 in the morning and saw a red fox run past.

Foxes hunt at night, any abroad by day raises suspicions of rabies. At home, if I see raccoon, skunk, or fox outside of dusk, dawn, and night, I will seek a weapon to dispatch the animal. In Barrow, we assumed rabies in all arctic foxes.

The furry red animal ran along the north side of the building, around to the west. I said, loudly, “There goes the fox!” and strode briskly to the other end of the clinic to try to get another look; I worried it might head to town. I didn’t see it again, and decided it dens either under the hospital or in the maze of construction dross nearby.

****

The first patient of the day felt really, really good after the vitamin B12 shot yesterday. Best in years; better sober after that shot than drunk.

Which made my day.

***

I leave tomorrow after an abbreviated afternoon clinic. Staffers have come in to wish me well. I got a great going-away card, a very trendy tote bag, and a pair of hand knit socks. Along with the story of the wool (starting with the sheep) and the WWI-era sock knitting machine.

Brevig back to Nome

March 31, 2015


I flew out and back Bering Air
My clothes in layers I’d wear
I come and I go
In the ice and the snow
And a bag of dry fish I did share

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 out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) I can get along with. Right now I’m on temporary detail to Brevig Mission from the hospital in Nome, Alaska.

I don’t sleep well the day before I travel, without regard to mode of transport. I rose early and showered and packed and ate.

Then I napped, for the best sleep I got all night. By 8:00AM I logged on to the computer.

I worked a steady pace through the morning. At noon the staff left for lunch. I stayed by myself and ate trek mix while I read a Jonathan Kellerman novel (I write better than he does, but he has the genre formula nailed down).

With but one afternoon patient scheduled, I had time to finish documentation. The Bering Air agent, who had showed up during a house call to check me yesterday, came in. The plane would be a little late, he said, flying from Nome to Wales first. He needed my weight. I offered to get on the scale (declined), and gave my best honest estimate. But he also needed weights on pharmacy and lab air freight.

Things had finished when the staff asked me to add in another patient. I looked at the clock. Plenty of time before the 4:00 departure. Sure, I said.

And I said that for the next three patients as well. I luxuriated in unhurried patient care. And each time I entered the data into the computer in a timely fashion.

I told the staff what a great time I’d had. They told me to come back in summer for prettier scenery. I looked out at the snow-covered hills and the frozen Bering Sea, and wondered how things could ever get prettier. They assured me they would. And they talked about how Brevig never sleeps in the summer, how the place bustles with activity. And about the fishing.

I said that I would have like to have tried dry fish.

The staffers looked at me in dismay. I should have spoken before, they said. And I saw how my shyness, from not wanting to impose on my hosts, appeared as standoffish. And all that announced at 3:50PM.

A Community Health Aid (CHA) bundled up faster than I could imagine, and jumped on her ATV.

It takes me a good deal longer to get on my arctic-grade bib overalls than the CHA’s near instantaneous preparation. As I mounted the ATV behind a diminutive staffer, we saw the plane coming in from the northwest.

The CHA on the ATV passed us on the hard-pack snow of the village street, and the staffer in front of me took the bag of dry fish from her without slowing, as casually as if it happened every day and as smooth as the railroad used to pick up sacks of mail. Approaching the airport, we saw the only truck in town, a 4WD club cab pickup.

I needn’t have worried about keeping the plane waiting. We pulled up before the pilot, working on his documentation, killed the engines.

Wearing my arctic layers let me confine my baggage to 1 day pack. I sat as instructed just behind the passenger in the co-pilot’s seat.

After a 5-minute flight to Teller we deplaned one passenger who had flown from Nome through Wales and Brevig to get home.

Ice melting into puddles astounded me when we arrived in Nome with a temp 20 degrees higher than Brevig when we left.

Contrast remains the essence of meaning, even when just barely above the melting point.


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