Archive for September, 2010

Comparing notes on what to look for in an employer, and how great reasonable hours are.

September 30, 2010

I went with a friend for a bite,

As the afternoon turned into night

    Comparing job notes

    Benefits, values, and quotes,

And the value of leisure delight.

Twenty-four hours ago I put data into a web site called DocCafe, which helps doctors looking for work get in touch with employers and agencies.  An avalanche of email followed.

I emailed my CV right and left.  Over lunch I spent two hours and all of my cell phone’s voltage talking to recruiters.

I spoke directly.  The ratio of jobs that fell through to jobs that panned out runs 8:1.  Yes, I said, go ahead and present me but I’m working with more than one recruiter.

After my lectures I met a friend for a sandwich.  Rebecca knew our daughter Aliya in college; she lived in Sioux City for two years and in that time befriended Bethany and I.  She lives in Lower Downtown Denver now, and, like me, finds herself between jobs.

We compared notes.  She commented on the importance of employer appreciation, and that interpersonal respect, money and benefits much be considered as a whole package.  I talked about my job during my premed years at Cybertek, the software firm that did United American Life’s computer work in a building four blocks from where we sat (the building has since had an appropriately committed relationship with a wrecking ball).  They trained me, paid me $.80 above minimum wage, let me study while I worked, and let me eat the leftover breakfast pastries.

Later in the evening I ran into an ex-partner.  Rick left our Sioux City group in 1993 to move to Greeley.  Recently a hospital purchased his practice, he stopped doing OB and making hospital rounds.  Now that he doesn’t get awakened in the middle of the night, he gets good sleep on a regular basis, and has more time.  He feels rejuvenated.  Actually he says he almost feels like he retired. 

When we shared our views, I commented on how much happier I am now that I’m not the boss, and we both talked about how we work too much, but how much we love the work.

The topic eventually came to accessibility of medical care.  Yes, we agree, all these things that we’re doing result in more leisure for us, but if all the doctors had a sudden attack of sanity and stopped working those life-shortening overtime hours, there wouldn’t be enough doctors.  And especially there wouldn’t be enough family practitioners.

I presented my plan: eliminate the premed requirements; democratize the pre-clinical med school years and put the information on the net for free.  Anyone who can pass Part I of the Boards should be allowed to continue into a clinical program. Those last two years of med school would be extended from two to two and a half years to cover everything relevant in premed and those skills that cannot be taught by computer (interviewing and physical exam).  Current medical schools, for a price, would teach those students who don’t do well with distance learning.  The result would be a much larger number of doctors willing to work fewer hours for less money. 

We agreed about the feasibility and improbability of such a scheme.

A medical convention down the street from where I did my pre med.

September 29, 2010

In Denver I’m out walking around

In the part they call lower downtown

     The town’s not the same,

     The game has sure changed

Since I left, med school bound.

For the first time that I can remember, the American Academy of Family Practice is holding their annual Scientific Assembly in Denver, my hometown. 

I grew up here, and I went away to college in 1968.  I came back in 1972 with a really spiffy degree from a prestigious eastern University and no marketable skills.  In January of 1973 I quit running from my destiny to become a doctor, but I had to go back to school to get my pre-med requirements.

I started the summer semester in that year at University of Colorado at Denver.  At that time it was housed in the rehabilitated Denver Tramway building.  Motivated students learned from professors selected for their ability to teach. 

Lower downtown Denver at that time had its sketchy areas, though gentrification had started on Larimer Street by then.  The Mile High City’s skid row festered a few blocks from campus.  Drunk Indians staggered past the bus stops, drunk cowboys found pawn shops and left their saddles.  Just plain drunks wandered from cheap bar to cheap bar.  Street people panhandled and looked strung out. 

Lean, hungry, and poor, I owned no car in those years when I lived in my mother’s basement thirteen miles away in the suburbs and cycled both ways.  Looking back, the three daily hours on a bicycle started me down the road to adverse time pressure.

I worked part-time at Cybertek, overnights and weekends, in the United American Life Building six blocks from school.  The firm provided computer services to the insurance company, and I put paper in the printer and cards in the reader.  The job didn’t pay well but it was convenient and I could study on the job.

Lower downtown is now LoDo.  The United American Life Building descended into rubble decades ago.  Well-used bicycle racks grace the front of many shops.  A pedestrian mall with free bus shuttle runs the length of 16th Street.  A sure sign of an affluent community, street musicians, play ukulele, saxophone, guitar, and even an upright grand piano.  The young people don’t look nearly as hungry.

University of Colorado at Denver in the 21st century resides at the Auraria Center and now looks like a college.

The country’s prosperity has increased in the last thirty-five years, mine along with it.  I’m not nearly as hungry.  I stay in a proper, air-conditioned hotel, and I drive a car. 

I still remember the hunger and cold, which increases my appreciation of the good things all the more.

The street people still panhandle. Still as numerous but made less noticeable by the prosperous, they look older but just as stoned.  I hear more European languages and more Spanish than I used to when I walk down the street.

I don’t hear Navajo or Ute any more.   I don’t see any drunk cowboys. 

And now I’m not in a hurry.

Contrast is the essence of meaning.

I’ve changed a lot more than Interstate 80

September 27, 2010

The traffic has sped up and slowed

I’ve changed my travelling mode

    This is Nebraska,

    It’s not like Alaska.

We’ve got the I-80 road.

I travelled Interstate 80 the first time at the start of the summer of 1968, going east from Denver on my first road trip.  I drove my friend’s new Chevelle directly away from my high school graduation.  Bitter about the previous seven years at home and at school, I determined to never return. 

At age 18 I had much to learn.

At that time I-80S existed only in segments, and wouldn’t be named I-76 until the Bicentennial.  I pulled off the two-lane in Julesburg, and while the attendant pumped my gas and washed my windshield I listened to the wind in the telephone wires and thought I’d heard the loneliest sound in the world.

The speed limit signs at that time changed from 70 to 80 with the daylight.

I drove to meet up with my music buddies in Illinois, sure we’d change the world with our music.

The summer didn’t go according to plan.  We came back to Denver in the middle of July when the pianist’s mother died.  The pianist and I didn’t find day jobs and we didn’t find much in the way of music jobs, either. 

I travelled west on I-80 that winter for Xmas break; I had yet to learn to travel light, yet to learn that school books brought on vacation never add to knowledge but diminish the vacation’s quality.  Again the three musicians rode in the pianist’s Chevelle, and got stuck in a snow drift outside of Cozad.

For the next four years I-80 served as my hitchhiking corridor to and from college.  When I went to medical school I traveled the same highway, catching rides or thumbing.

Bit by bit I-76 reached completion and the four-lane finished skirting Omaha.   

We moved to Iowa in 1985.  At that time the speed limit was 55 and we had three small children.  The twelve-hour drive to visit my parents thus dilated to eighteen hours until we learned to drive at night.

In May of 1989 I received a call as the sun was going down.  My stepfather had a stroke; my mother told me not to come.  Bethany brewed me a Thermos of real coffee and I left immediately.   He died four days later, and I drove back with the radio off, alone with my thoughts.

My mother got sick in 1991 and died in 1993.  During that interval I made the trip many times by air and by car.  I learned how dead-end and bitterness define each other, and sap the joy from life.

We made the pilgrimage every summer to visit my father till the kids grew up and my father died.  I travel I-80 less often now than I used to.

I have taken to making the trip in two stages; I have stopped tonight at a motel in Big Springs, now that I have a level of affluence that I didn’t have the years that I travelled all night or camped briefly in Grand Island or slept a few hours in a rest area.  Quieter, safer cars speed back and forth.   Speed limits have gone down and then up.  Gas mileage keeps improving.   Nebraska highway maintenance remains a model of functionality. 

I am on my way to an educational conference in Denver through the American Academy of Family Practice.

In the last forty years I’ve changed more than the road has.

This trip is the first time I haven’t been in a hurry going or coming.  I’m enjoying it a lot more.

Pain, sleep, and language acquisition: Rosetta Stone is better than Rozerem

September 26, 2010

If a language you’re wanting to study,

And fix up your sleeping so cruddy

     Rosetta Stone’s fine

     To tone up your mind

And clear up your thinking so muddy

In 1999, in a bid to improve my sleep pattern and thereby help control my chronic pain, I bought Rosetta Stone.

Human language is so complex, and we’re so good at learning it, that the brain changes physiology during language acquisition. 

In the normal course of events, a newborn spends 50% of the time in REM sleep, at a time when the brain is undergoing the biggest intellectual task of its life, learning how to listen and talk. 

As time goes on, one spends less and less time in REM.

We don’t really understand REM sleep but we know that learning becomes very difficult without it; impair your REM and you lose resistance to disease, emotional resilience, and skin elasticity, among others.  Percentage of REM increases during language acquisition.

I used Rosetta Stone intermittently over the years.  As the company updates their programs I keep buying the new version. 

When I use the program I sleep better and my back hurts less. 

Chronic pain cannot be controlled in the absence of good, restorative sleep.  Everyone knows that pain level five becomes a six or a seven after unrestorative sleep, or a three with a good night’s sleep.  People who don’t hurt at all will start to ache if you don’t let them sleep; thus fibromyalgia depends on sleep deprivation.

People with rheumatoid arthritis (RA) sleep poorly and they hurt.  A recent study showed that sleeping poorly predicts pain during the day more than pain during the day predicts sleeping poorly.

I never prescribed sleeping pills before zolpidem (Ambien) came on the market.  We now have four good prescription drugs to induce restorative sleep: Sonata, Ambien, Lunesta, and Rozerem.  Each has a different place, all of them will help a person sleep and help them rest.

Rozerem is the best at putting a person to sleep, but it won’t keep that person asleep.  Thus it’s good for new mothers or others  who have trouble switching off their minds so that they can fall asleep.

Sonata is a good four-hour sleeper, it’s for those who have to make the most of the few hours they’ve allotted to be in bed.  As such, except for those people who get six or seven hours out of it, it performs a function but doesn’t solve the problem.

Ambien or its generic equivalent zolpidem will put a person to sleep and most will stay asleep for about eight hours (I have had patients who got twelve hours and a few who only got four). 

I reserve Lunesta for those alcoholics who didn’t respond to my pleas to quit drinking nor to my prescriptions for zolpidem.

But mostly I prescribe the non-pharmacologic approaches to sleep management: good sleep hygiene (Google “rage, hunger, lust, and sleep”), and study a language.

I got the newest edition of Rosetta Stone, now with Levels 1,2, and 3.  I’ve been studying an hour to an hour and a half a day.  It helps my sleep, it which relieves my back pain, and now I can speak Hebrew

From Alaska to Nebraska, contrast is the essence of meaning.

September 24, 2010

Today while planning my work

I went faxing to recruiters and clerks

    From Barrow, Alaska,

    To Grand Island, Nebraska,

This business has plenty of quirks.

I spent much of the day hustling up work. 

When I decided to make my career move in February I planned to do a palindromic geographic reiteration of the places that had brought me to Sioux City in 1985, but things didn’t work out.  Instead I made a very long first step in this next phase of being a doctor, to Barrow, Alaska, as far north as a person can go in the United States.

At about that time I put too many items on my list for a year: an armed forces installation, an Indian reservation, New Mexico, Wyoming, and a prison.

It turns out that the defense bases need a lot of doctors but want a six month commitment. 

I’m currently getting credentials for an Indian reservation clinic, and a one month placement in a prison health facility looks good.

I have confirmed an actual job for the last week of October in Grand Island, Nebraska. 

Most people in this country think of Interstate 80 when they think of Nebraska, and their conception is of a flat, boring place.

I would agree that the Platte River Corridor is boring, but Grand Island lies just south of the Sandhills.

A majority in this country, including most Iowans and a distressing number of Nebraskans, have never heard of the Sandhills, a place of quiet and peace and incredible beauty. 

At the end of the last Ice Age, sand accumulated in dunes in what is now western Nebraska, Kansas, and South Dakota.  When the Europeans wiped out the buffalo, the natural overgrazing stopped, and the dunes sprouted grass.  In the last hundred and twenty years, the Sandhills have been able to support more and more life.  Because water moves freely through the sand that comprises the district, many lakes dot the area.  The water table is very shallow, though scant rain falls.

The air is clear there, and the sand soaks up the sound.  The first time I went I was struck by the lack of noise.

I enjoy Sandhills people.  There is no pretense about them; if there are 200 people in an area the size of Rhode Island and half of them live in town, there is no room for a phony but there is space for almost everything else. 

Once, in Arthur County, I tried telling a shaggy dog story, but I did it with a straight face, and when I got to the punch line, nobody smiled.  At the point I realized that if I would impose on the sensibilities of my audience for such a tale, I would have to announce it as a joke.

Market forces, business opportunities, capitalism, Spanish, teachers, and ESL

September 23, 2010

It doesn’t matter the language you speak

If it’s a meat cutting job that you seek

     English won’t vanish

     It displaces Spanish,

Disappearing with nary a squeak

At dinner this evening we spoke with another couple.  The male had attended a one-room school; there were twenty-two students in eight grades, the eighteen-year-old teacher finished high school, and the two German students didn’t speak English.  “No ESL then, I’ll tell ya’.”

A few months ago a major pork processing plant in Sioux City, John Morrell, closed.  The outdated physical building lost efficiency compared to new buildings; we all knew it was only a matter of time and wondered that it took so long.  Sioux City has depended on meatpacking for more than a hundred years; the business model has changed a great deal in that time, but the nature of the work hasn’t changed much.  The labor-intensive activity of turning a hog into pork chops, ham, bacon, and sausage is still cold, dirty, and boring.  You can earn a living wage without English.  It has been an attractive occupation for some in the deaf community.

Our town has depended on waves of emigrants since the 1880’s.  Germans, Swedes, Norwegians, Greeks, Lithuanians, Syrians, southeast Asians, Hispanics and most recently Somalis came to the slaughterhouses to work.  They faced discrimination and prejudice, and the rhetoric has changed very little since the beginning. 

Mostly I hear monolingual Americans complaining about the largest, most recent wave of immigrants, the Hispanics, in linguistic terms.  Stereotypes, even negative ones, dwell on hardworking people with close family connections.  “Let ‘em learn English,” I hear; “I don’t want ‘Press one for English.’”

Before the dinner conversation degenerated I said, “You know, being a capitalist, where other people object to linguistic accommodation, I see a market opportunity.”

Bringing capitalism in a conversation with patriotic people usually puts a new spin on things.  “I speak Spanish,” I said.  “When I left my practice after twenty-three years I was doing half my business in Spanish, and man, have I seen the changes.  Twenty years ago a person with a Hispanic last name generally didn’t speak English at all, but had a big wad of bills in their pocket, and expected to pay cash.  And when they did that, they took my advice.  I’d say ‘Quit smoking and drinking,’ and they’d quit smoking and drinking.”

The other people looked at me in amazement.  I thought they were going to ask me patients taking my advice but the lady said, “You speak Spanish?”

“I hit fluent forty years ago and I’ve just kept getting better since,” I said, “And really, we’re talking about hard-working people who would really like to speak English, but they don’t have the time to learn because they’re working overtime and irregular shifts in jobs that a lot of other people wouldn’t do.  Besides, it gives my wife and daughter work; they’re teaching English as a Second Language through the Community College.” 

In fact, Spanish is an endangered language here.  The first child is bilingual, and teaches the younger siblings English.  Frequently the youngest child can’t speak Spanish and can’t talk with the parents.

I can’t stop being a doctor, I don’t want to try. I just want to slow down.

September 22, 2010

I can’t stop being a doc

Leave me alone and I’ll diagnose a rock

     Say what you please

     I can see a disease,

Sometimes from the end of the block.

I can’t stop being a doctor.  I have a one-year, thirty-mile non-compete clause, so I can’t give advice or write prescriptions unless I am out-of-town.  But at the same time I make a purchase at a store or talk to someone on the street I can’t stop making diagnoses.

I can tell the sleep deprived people by the fine wrinkles on their faces, the front parts of their cheeks, and the bags under their eyes.

A particular kind of hyperthyroidism, Grave’s disease, shows itself in prominent or bulging eyes; actor Marty Feldman displays this eye finding, exophthalmos, which overlaps incompletely with a visibly enlarged thyroid, or goiter.

Parkinson’s disease displays several early findings before the tremor starts.  People walk rigidly, their smile seems frozen, they start to lean. 

People with neuropathy walk with a broad-based, uncertain gait, something like Frankenstein’s monster in the original movie. 

I looked at a clerk’s hands today and noted a rash on the left hand in the web space between the little finger and ring finger; red and swollen with sharp edges.  I wanted to tell the person that a fungus was growing there, and to use over-the-counter antifungal till it cleared.

Another person had some fine red bumps on the inside of the forearms; whether insect bites or poison ivy or other contact allergy didn’t make any difference.  I had the urge to instruct on the use of over-the-counter 1% hydrocortisone cream for itch, and to ignore it if there were no itch.

I can smell the smokers by the smell, sometimes I cough from being near them.  I want to offer advice, but I don’t if I’m in town.

I miss my work but I don’t miss the sleep deprivation.  I’m looking forward to going back to medicine on a forty-hour a week schedule. 

I’m arranging my next placements.  I’m having trouble deciding where I want to go during the month of October.  Do I want to take a job for fewer hours but better rate with very short commute, or do I want to drive further?  I know I want a better adventure, but possible work availability complicates the picture.  With many variables in many unknowns, eventually I have to commit to a course of action.

This morning at the Care Initiatives Hospice meeting we talked about patients and I made more recommendations for decreasing or eliminating drugs than I did for starting new drugs. 

At the end of the meeting, I was the first one in line for the flu shot. 

Last flu season went easily probably because we immunized so well.  The H1N1 wasn’t nearly as bad as we’d thought.  The possibility of a change in virulence remains, but looks a lot less likely.

I can’t stop being a doctor.  I don’t even want to try.  I just want to slow down.

I love the smell of napalm in the morning: muzzleloading in Ponca State Park

September 19, 2010

You know, I said with a grunt,

Some just think it’s a stunt,

    With no scope for a sight

    And a load that is light

And a rifle that loads from the front

I went out to Ponca State Park this morning for their annual Outdoor Expo.  Because I’d been so busy in the past I hadn’t attended before, but this year when the Hawkeye Rifle and Pistol Club asked for volunteers, I couldn’t say no.  And I didn’t want to.

Back in February of 1988, my new partner at the time, John, picked up a flyer off his desk and said, “Did you see how long the muzzleloader deer season is in Iowa?  It’s almost three weeks long.”  He put down the flyer and he picked up an identically sized catalogue.  “And did you see how much muzzleloaders are at Comb’s?  They’re $99!” (Comb’s Authorized Liquidators has since changed ownership four times and to the best of my knowledge is out of business.  But they were fun while they lasted.)

For twenty dollars less I bought the kit, mail order.  One of my best stories to tell a live audience is my “take-it-apart-put-it-together” saga of Me and the Ten Failed Muzzleloader Kits.  If you ever meet me and ask for it, I’ll tell the story but it has a lot of visuals that don’t translate to the written page.  In July of that year I bought an actual front-stuffing rifle from Thompson; it served me well for fifteen years until the stock cracked under horrendous weather conditions.  The manufacturer stood behind their product when they didn’t have to, and that’s another very long story.

That summer John and I learned how to shoot and maintain our new rifles.  Over the next five years at least one of us took a crippled deer each year. 

As time passed I acquired a flint-lock, two Civil War era reproductions, modern in-line front loading weapons, and a bunch of spare parts.  I have taken deer and elk for meat. 

I naturally fit in as a volunteer at the Club’s muzzleloader booth.

We kept the loads light, about 40 grains of a black powder substitute propelling round balls with a greased linen patch.  Nobody complained about the recoil.  Several people shot very well.  Lots of folk didn’t know how to aim without a telescopic sight. 

One volunteer gatekeeper, four loaders, and four coaches kept the crowd moving.  It was a good mix of ages, ethnicities, genders and experiences.   A lot of women fired a gun for the first time. 

 At some point I found myself both loading and coaching.  After a few shots my loading went very fast. 

We took a break while three mountain man re-enactors gave a great flintlock demonstration.  One fellow got a shot off every twenty seconds.  Another man dressed correctly for 1760 used a historically accurate “trade musket” loaded with a handful of powder, leaves from the ground for a first wad, a handful of gravel as a charge, and more leaves for a top wad.  He pointed out that with flint and powder he could still have a weapon with whatever he found lying around.

Filling out forms, a disagreeable lifetime pursuit

September 18, 2010

Every day since I left the dorm

I’ve had to fill out the form

     They’re never the same

     Except they ask my name

And how well that I stick to the norm

 In my senior year of high school I got so fed up with filling out forms that I put twenty items on a questionaire, titled it FILL OUT IMMEDIATELY, and left fifty copies at the school’s front desk.  Forty-six forms were filled out.  I don’t like filling out forms, and what goes around comes around.  I think I’m being punished for my prank.  As life goes on, the forms get more frequent and trickier.

I’ve been filling out forms to find new locum tenens jobs.

Even where I am a known quantity with a good reputation, I have to supply the same information.

They all want to know where I’ve worked, where I went to school, where I have licenses, if I have physical or mental problems, if I have alcohol or drug problems, if I’ve ever been convicted of a crime, if I have ever been taken off of Medicare or Medicaid rolls, if I’ve ever been sued, if I’ve ever been refused privileges at a hospital or been disciplined there.

But are the same and the questions are all phrased differently.  “Have you ever been convicted of a misdemeanor or felony in any jurisdiction of the United States or other country?”  is not that same as “Have you ever been convicted of a misdemeanor or felony aside from minor traffic violations?”  I answer the first one with my five parking tickets, my one moving violation, and my conviction of being an illegal pedestrian (I’m not joking).  For the second I can check the No box.

Some ask for the day, month, and year when I started and stopped certain activities, some for the month and year, and some just ask for the year.

They also want copies of my licenses, medical school diploma, and Continuing Medical Education (CME) activities.

I would think that in the twenty-first century checking me electronically would be more reliable than looking at photocopies of paper documents. 

A number of countries would like to import American doctors; one such country’s eighty-seven page query document collection is written so opaquely that even though the official language is nominally English I can’t understand the forms; I’ve been working on them for months and each time I get the jitters.

Today I went down to Staples and got copies made of the certificates which are most asked for: med school diploma, residency certificate, state medical licenses, the details of my legal history, and DEA permit.  I left with five copies of the packet.  I’ll need them. 

I’ve been talking to recruiters for spots in New Zealand, Wyoming, Dubuque, an Indian Reservation and Grand Island.  I’m stoked.

Of course I have to remember that many plans fall through at the last minute.

I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks out I’m having adventures.  To comment on a post, click on the title.

The three week rule, revisited.

September 16, 2010

It happens, even to me

And always during week three

     On day twenty-one

     Of exercise fun

I’m as sore as a body can be.

I started to ache last night while I was writing my post.

At the time I attributed it to overdoing the exercise, or maybe to my anklylosing spondylitis (which deserves its own series of posts if not its own book) combined with a falling barometric pressure.  My daughter, Aliya, has the same problem, and when she sat down beside me I asked if she were having problems.  She replied in the negative.

So I did what I usually do when I start to ache in the evenings, I hydrated and took two extra-strength acetaminophen (also called Tylenol).

I got really good at hydrating in the five years that Bethany and I did a diet and exercise program (UBC), and I found out that a lot of discomforts really come down to a lack of circulating water.  Drinking a glass of water every fifteen minutes till my urine turned clear worked wonders.

Bedtime arrived an hour later and I felt better but not well.  Deep sleep escaped me for the first time in weeks.

When I woke up this morning I realized that the three-week rule had snuck up on me once again.

Everyone knows that if you start to work out you get worse before you get better because you have to heal from the damage of the workout and that takes time.  If we know that human healing is a six-week process (the last time you sprained your ankle it took six weeks before all the soreness went away) and if we know that healing takes place in accelerated fashion in the first two weeks and if we do the arithmetic we can see that the breakdown stacks up at three weeks before the healing has really kicked in.

Every January 21st I see a wave of athletic injuries in people who made a New Years’ resolution to lose weight.  Having gotten away with severe exercise in high school, they figured they could do the same thing twenty years later.

The process applies on a neurologic/endocrine/immunologic basis as well.  If you make a major change in your life, the chances that you’ll be hurt peak twenty-one days after the change.

So today I waltzed through my workouts, I didn’t push resistance, time or tempo.  I kicked back, took it easy and ate a lot of carbs. 

Most exercise programs fail in the third week because of the three-week rule.  People will find any excuse not to go back to the gym at those times; the ones who continue their program start to get the payoff in the fourth week and keep going back because it feels so good.

The first morning I was back in Sioux City I reactivated my gym membership and worked out for a half hour on the elliptical machine.  I’ve been going an average of five days a week since.