Archive for October, 2010

You meet the nicest people around a shotgun

October 31, 2010

Found ammo is better than loot

But friends are a much bigger hoot.

     The lesson I got

     For the shotgun I brought

Improved the way that I shoot.

Men like projectile weapons.  If we didn’t have constraints like time and money, most of us would do little else besides practice.  As kids we never got our fill of shooting because our dads had limits like time and money.

Thus men of retirement age gravitate towards sporting clays courses, trap ranges, golf courses, and archery lanes. 

Today I took my shotgun to Grand Island’s Heartland Public Shooting Park. (Explanation: a shotgun cartridge contains multiple pellets.  Today, I used loads of #8 shot, about the size of poppy seeds.  Good for killing clay targets but not for much else; you can buy them in Castro’s Cuba.) 

The facility ranks as the nicest shooting park I’ve been to.  It has up-to-date equipment, well maintained paths, and great habitat.

The sporting clays shotgun course covers seventy-five acres.  A mile-long gravel path encircles it. 

I enjoy a lot of things about shooting sports, among them the camaraderie and socializing.  A stranger here, I had to set out on the course by myself. 

Still, the weather cooperated and at the first of ten stations I hit 7 of the ten electrically thrown targets.  

At the third station I found a whole box of shells.  A brand I’d never heard of, Rio, with bright blue plastic husks, the only words on the box not in Spanish were MADE IN TENNESSEE.

Ammunition constitutes the biggest cost in shooting.  Occasionally one might find a shell that another shooter has dropped; to find an entire box outranks finding five dollars. 

I resisted the temptation to shoot them all right there.  I put them in my backpack, telling myself I’d turn them in at the clubhouse when I was done, then thinking, Yeah, right.  I grinned to myself as I walked away from the station and a button buck deer crossed my path.  

I considered the irony; the deer can’t find a safer place to live than a shooting range.  People who own firearms tend to be law-abiding.  No one would risk getting kicked out of a shooting park for discharging a firearm in the wrong place at the wrong time. 

As I walked up to station #4 I saw two golf carts pulling away with five people.  Even at a walk I caught up with them at station #6.  I pulled my muffs from my ears and asked, “Who’s shooting Blue Rio’s?”

They all were.  I told them I’d picked up a box of their shells, they invited me to shoot with them.

Tim and John were teaching three adolescents.  As I got into position, we saw a rooster pheasant gliding into the thick switchgrass ahead of us.  I had just loaded my 12 gauge when one of the young adults pointed out a deer almost hidden in the tall grass, less than 50 yards in front of us, probably the same button buck I’d seen earlier.  He stared at us for a while, got bored, and browsed off into invisibility. 

I didn’t shoot very well; Tim gave me some pointers, and I smoked two flyers in a row. (When one hits a clay target with enough pellets, it breaks into a cloud of debris, like smoke.)

I had a yoyo in my backpack and I did a minute’s worth of tricks.

“You know,” Tim said, “You meet the nicest people around a shotgun.”

Of chest pain and delusional GPS units

October 30, 2010

The chest pain is the worst part

Though a work-up was done at the start

     I’m out here in rural

     So I got a referral.

The problem, I think, is the heart.

I call my GPS unit Sweetheart.  Most of the time she (she speaks with a feminine voice) reliably gets me from place to place. 

Once in a while she loses contact with reality; while Bethany and I were driving from Anchorage to Fairbanks, north of Denali she became quite confused and wanted us to turn left when all we could see was roadless moose, bear, and wolf habitat.

I drive 1.3 miles from my hotel to the clinic where I work, and most of the time Sweetheart guides me correctly.  About one-third of the time, in one particular segment of the drive coming or going, she gets confused and tries to have me do maneuvers ranging from U-turn to cloverleaf.   I’ll usually say something like, “Are you sure, Sweetheart?  Did you take your medicine today?”  I’ve now learned the route, and the places where she becomes delusional, and I’ve taken to not turning her on to get to work.

Friday afternoon I took care of a third grader, whose mother gave me permission to include the information below.  With a main complaint of cough, he has a long history of chest pain and pallor with exertion.  Sometimes if he plays too hard he has to stop and rest.  His cough started with one of those episodes.

The mother read the alarm on my face, assured me the patient had been to a pediatric cardiologist, and described a thorough work-up.

The mother and I agreed in our lack of comfort with the situation and the desirability of a second opinion.   I called one of my colleagues and friends, a pediatric cardiologist in Sioux City.  I gave him the story and he accepted the referral.  Then I told him why he hadn’t heard from me since May, what I’d been doing and where I’d been going.  I explained that my non-compete clause doesn’t apply thirty miles away from Sioux City.

After we hung up I gave the mother the doctor’s name and phone number so that she can call and schedule an appointment.

Then I did yoyo tricks for the patient.

No doctor practices in a vacuum, all of us depend on a referral network; I’m most comfortable sending patients to doctors I know and trust.  In this case, I didn’t know the pediatric cardiologist the patient had seen, but I knew the history sounded like a heart problem.

There is no substitute for thinking things through.  No matter how good your GPS unit, you still need to watch where you’re going.

Advising a potential doctor after a good day in the clinic

October 28, 2010

I said to a friend of a friend,
Consider the time that you’ll spend
    And the cash you’ll be burning
    For medical learning
And the terms of the Federal lend

I take care of patients and I cannot write identifying information. They are male or female or confused; they do or they don’t work, they are or they aren’t students or teachers or either or neither or both; some drink to excess; many smoke; each is a part of a family unit and has a social context. They all have feelings; the adults all have sexuality. Each has urges to evil and good in various strengths and directed with differing degrees of mastery.

Today I saw patients for colds, coughs, pink eye, sports physicals, sore throats, urine infections, STD’s, hives, ankle sprains, ringworm, and well child checks.

One patient’s family includes three generations of jockeys, one of whom rode the Kentucky Derby three times (I have permission to include that information in this blog).

My patients bore Polish, Hispanic, Irish, Scots, Czech, English and Indian last names; some had mixed Native American facial features.

One parent and child interrupted each other constantly despite a great deal of apparent love.

I gave advice about nicotine, caffeine, alcohol, trampolines, foot odor, ear wax, seat belts, sleep, exercise and diet.

One person, betrayed by a lover, wept.

Two families were affected by alcoholism.

The clinic today opened at noon and we went till eight.

When I got back from work I called a friend of a friend, actively considering a medical career. No matter what you think medicine is, I said, it will not be that when you finish your training; it will have morphed into something we cannot even imagine. No career holds more honor, few have more job security. These things will not change: people will get sick, sick people want to get well and they do not want to see unfamiliar faces; healers will hold a high place in society and they will be fed.

Becoming a doctor requires an investment of two years for premed, four years for med school, and three years for residency; the money invested pales in comparison to the time. Government programs that finance the education demand payback on a year-for-a-year basis, and pay a fraction of what could be earned in private practice.

I had a National Health Service Corps scholarship to medical school; they paid tuition, books, and a stipend.  I worked in the Indian Health Service three years past my obligation because my time with the Navajo enriched my life beyond measure.  When I left my income doubled every six months for a year.

Medical school changes the person who enters. Someone who seeks only riches will either drop out of the program or will change their attitude; the same can be said for those motivated purely by altruism.

The doctor who doesn’t put first things first in his or her own life won’t last in the profession. The doctor who neglects physical needs, such as eating, sleeping, human relations, and medical care, will burn out.

Pick a specialty, I said, based on what you’re good at and what you love. Don’t go into something because you admire a particular specialist.

Gravity therapy for sinusitis

October 27, 2010

When I say no it causes a scene

Because the truth is not what it’s been

     It’s a plus or a minus

     Antibiotics for sinus

Whether or not the mucus is green.

Sinusitis hit me in the winter and then spring of 1973.  At that time I lacked money for a car or for a doctor.  A bicycle carried me from point A to point B, and for weeks and then months the cold Colorado wind drove spikes of pain into my inflamed sinuses.

Poverty loves company more than even misery does.  I fixed a friend’s bike and in return I got the yoga treatment for sinusitis: hang your head upside down for five minutes.

It seemed hokey to me, but even if I had no money I had time, and per instructions I lay crossways on my bed, face down, with my mid-chest hitting the edge of the bed.  I relaxed and, sure enough, the top of my head pointed at the floor.  Four minutes later I felt a pop around my eyes and gross brown liquid drained out my nose by the teaspoon.  When I stood up my sinus headache had disappeared.

At the time I knew no anatomy nor physiology; I had no idea that the sinuses under the eyes drain uphill, and when a cold or allergies attack the outflow becomes blocked by swollen tissue. 

Medical school physical exam taught us to apply pressure on the cheekbones if we suspected sinusitis; if the patient experienced relief, they said, antibiotics would probably cure the problem.  One day in the late ‘80’s while performing that maneuver, I heard a loud squeak, gurgle, gurgle, and the patient experienced immediate relief.  Since then I’ve tried the same technique hundreds of time and never replicated the results, though about a third of the patients will experience some improvement.

Decades ago the truth about sinusitis ran something like this: antibiotics only help if the mucus is green.  Since then, we’ve found out that sinusitis gets better 85% of the time with antibiotics and 75% of the time without them.  Which means that for every one person I really help with amoxicillin, seven others took the medication for no good reason.  Oh, and color of mucus doesn’t make any difference.

In my current position I’m seeing a lot of “sinusitis” and I don’t prescribe antibiotics.  The medical profession did such a great job selling the public on the need for those drugs for this diagnosis that unselling becomes problematic. 

I can write a prescription for the latest -cillin or -mycin much faster than I can explain to a patient why they don’t need it; naturally there are those docs who find themselves behind schedule and cave in to the pressure from the patient.

Re-education for physicians and the population will take time.

A doctor burning out and two who aren’t

October 27, 2010

Here’s the truth I wanted to share,

Improving medical care.

     Here they do what they should

     And it’s coming out good

I’m just trying hard not to stare.

In the Chicago airport I listened to a man carrying on a serious conversation.  “It’s a problem,” he said.  “And it’s been a problem for a long time and it needs to get fixed.  And when I get back, no, YOU listen, and when I get back, I’m going to, no, you’re NOT, now YOU listen.  He needs to have an admission arranged to (I didn’t catch the name C hildren’s Psychiatric Hospital.  Yes.  Locked unit.  Now you call Dr. (I missed the name), and you tell him…I told you already.  Yes, it’s a problem.  Do you have it?  Now it’s serious and I’m going to be gone for two or three days but it needs to be done, I won’t be back to Richmond till Sunday and you need to handle this.  It’ serious.  And when I get back I’m going to work on fixing this problem, it’s gone on way too long.”

Clearly, spoken by a doctor in need of a vacation who makes sure his stress follows.  I suspect he has trouble giving up control.

He stood my height, and outweighed me by eighty pounds.  What little remained of his hair was white.  Bags under the eyes, skin hanging on his face, and entrenched frown lines bespoke chronic sleep deprivation and rapidly approaching burnout.  When he stood his shoulders sagged under the weight of his worries and he walked with the painful-foot roll.

He stood in line.  I wondered how much he generates his own misery and how much comes to him unsolicited.

Today I worked in Grand Island, Nebraska.  The clinic anticipates going from paper based to electronic medical records in March.  They will start that painful process much better prepared than any other medical office I’ve seen.   The doctors have maintained the paper charts well; the staff purges information not likely to be used on a regular basis and stores it for ready access.  Training the staff on EMR ranks as the transition’s hardest part.  Right after that comes the uploading of information from the paper chart.  The data will move much more easily than I’ve seen it move in the past.

Three of the patients I saw today suffered from problems related to the three-week rule:  twenty-one days after a stressor, the patient gets sick or gets injured.  None of the people I saw today smoke; two have retired.  Work moved at a reasonable pace, and the patients came with realistic expectations. 

The records show consistently excellent, thorough medical care.  Some of the more esoteric lab tests I could think of were already on the chart.

I haven’t met the docs here, but I suspect that the physician who went on vacation left behind his cares and didn’t take any loose ends to fetter his rest.  The doctor who puts first things first runs little risk of burnout.

I’m learning a great deal from this experience.  I look forward to figuring out the elements of the corporate subculture that bring this high level of functionality in the context of thorough medical care.

Twisted sex, serial killers, female victims, and creepiness: the formula for a successful book

October 23, 2010

Lots of docs are wanting to write

But find that the time is too tight

     If they had what it took

     To author a book

They’d be at it all of the night.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year, thirty-mile non-compete clause runs out I’m having adventures and writing about them.  I’ve worked in Barrow, Alaska (the northernmost point in the United States), I went to the American Academy of Family Practice Annual Scientific Assembly in Denver, and I took a week to visit a suddenly stricken friend.

I’m at a conference in New England for doctors who want to be writers.

I was expecting to run into physicians burning out and casting around for something else to do.  Instead most of the attendees have great imaginations.  A few want to write but haven’t; I suspect that they won’t.

I have written six novels so far; I’m working on a seventh, and only one is a medical thriller.  None have been published, and I don’t have an agent.  I had an agent at one time; I sent him a total of 21 copies of the novel he agreed to represent, and when he asked for more I stopped corresponding with him.  That was back before email made letters obsolete and cell phones made long distance calls free.

I have learned so far that you can say “he said” or “she said” as many times as you want, but if you use any synonym you’d better have a darned good reason.  Minimize your adverbs.  Always have your hand on your heart when you write, if your emotions don’t come through your audience will soon get bored.  Women buy seventy-five percent of the books in this country, and most of them like stories about twisted sex, serial killers, and female victims.  Creepiness sells.  Most people feel like they’re outsiders.  Show, don’t tell your readers.  Don’t name a character who appears only once.  Traditional publishing has a limited life expectancy; ebooks will dominate the future, are vastly easier to publish and much cheaper to buy.  Preceding publication of your book with a strong social network, especially Facebook will greatly increase your sales.

Much of the above makes sense but I didn’t know about the gender gap in sales and plot preference.

When Bethany and I lived in Wyoming we counted a real author, Win Blevins, as a friend.  At the time we knew him he had 18 books in print.  He told me that the people who should write are the ones who have to write; few people make a living by writing. 

I’ve been talking with some docs who want to be writers but they don’t love writing.  Or even if they do love writing, they don’t love it enough to have made time for it. 

I think people need to do what they love and what they’re good at.  When they find something that fits both criteria they enrich the world and they enrich their own life.  But they also need to know when enough is enough.  No matter how much you love something, you can always burn out.

A privileges and credentials packet goes out

October 22, 2010

It’s not the status that’s quo,

After quite a few flops in a row

     It was quite a long caper

     To fill out the paper

And the agent came through like a pro.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year, thirty-mile non-compete clause runs out I’m having adventures and writing about them.  I’ve worked in Barrow, Alaska (the northernmost point in the United States), I went to the American Academy of Family Practice Annual Scientific Assembly in Denver, and I took a week to visit a suddenly stricken friend.

Yesterday I got together the final paperwork pieces for the job I plan to take for the month of December.

A new medical position never runs without complications; a locum tenens job where the duration is short carries its own complications.  A Curriculum Vitae precedes any negotiation.  So far all prospective employers have asked for copies of medical licenses, residency certificate, medical school diploma, DEA certificate, CSR certificate (a state registration that qualifies a doctor to prescribe narcotics and other controlled substances), along with work history, malpractice history, and criminal history.  If the process continues, there’s a questionnaire from four to eighty-seven pages long (I didn’t fill out the monstrosity intended for another country; I decided I’d rather go somewhere else than spend weeks completing paperwork) which is sometimes accessible online.  And if all goes well, at the very end comes approximately twenty-five pages called Privileges and Credentials.  This last batch recaps everything submitted so far with a few more things thrown in.

The agency I’m working with took the information I’d given prior and filled in most of the P&C form. 

As I’ve said yes so far to 17 jobs (of which three have panned out), I’ve gotten good at completing the paperwork.

I got a call around noon, asking me if I’d like to have the raw material for privileges and credentials FedEx’d or emailed.  As I’ll be out of town for two weeks, I of course asked for the PDF file.  I printed it out at 1:00 PM and went to work.  At 1:38PM I called with some clarification questions.  I had to phone to find out the number of my professional liability insurance policies for the last seven years as well as the email addresses for those docs I’ve listed as references.  At 2:00 PM the material was ready to go.  However I had to learn how to use the FedEx system.  After a few more calls, and a light lunch, I dropped the material off at the FedEx store nearby.

I’m not complaining about the process.  Indeed, for the last 22 years I’ve sat on St. Luke’s Credentials Committee.  We’re very careful about who gets to practice, as every hospital should be.

This same agency’s recruiter has shown exceptional attention to detail, asking me to specify six parameters of reimbursement before she started negotiating with the client.   Yesterday afternoon I received my schedule as well as reimbursement plan, about 4:00 PM.

Regretfully, not all agencies have been so well organized.


Life lessons from tomatoes and uncertainty.

October 20, 2010

Boy, the summer went fast!
You know, I was having a blast!
The garden is lost
If we get a hard frost
This tomato might be the last.

Back in June I set out a garden with poblano chiles and six varieties of tomatoes. I put down mulch and a soaker hose to make it low maintenance, and a mesh fence inside an electric fence to keep out the herbivores. While I was braving temps barely above freezing in Barrow, Alaska, the sun shone warm on the garden and the rain fell voluminously and the plants grew tall.

When I came back at the end of August I found few fruits but a lot of foliage and I added MiracleGro for Tomatoes (they’re not paying me to write this); the plants blossomed and set fruits. Now in the third week of October we have a bunch of chiles and tomatoes at varying stages of ripeness.

In years past, I covered the garden at night when the first frosts threatened. The chore of spreading out the sheets and anchoring them requires two people. One evening our oldest daughter, Jesse, helping me for the tenth night running, said “You are trying to hold back time. This cannot be done,” referring to a beautiful children’s book set in Navajoland called Annie and the Old One.

I have not covered the garden this year; we have avoided the frosts so far. But I’ll be gone on a locums job for two weeks, starting Friday. The plants will have to fend for themselves while I’m out of town.

Bethany and I harvested hot peppers and tomatoes this evening as the sun dipped below the horizon and the chill chased the warmth from the air. Most of the tomatoes we picked green and brought to a neighbor who likes to fry them. I looked through the red, ripe ones, and picked the best of the bunch.

Many years ago I talked with a man whose family runs a tomato canning concern; he explained that a tomato can put its energy into cellulose (a lot like cardboard) or sugar. If the fruit has the internal structure to withstand handling from garden to store, it didn’t make the tart sweetness that gives a tomato its magic flavor. No store-bought tomato can match the taste of home-grown, vine-ripened fruit.
Tomatoes are part of a summer experience, it was good to have them from my backyard when I came home, but the end of tomato season rapidly approaches.
I prepared a take-and-bake loaf of sour dough, and made a tomato sandwich with the warm bread.

The garden might still be alive and producing when I get back in the first week of November, but chances are it won’t be, then I’ll have to make do with the pink tetraploid unbruisable products that are more suitable as projectile weapons than as sandwich material.

My tomato sandwich this evening might not be the last for the year, but I savored it as if it were, embracing uncertainty.

A mistake booking my reservation costs me a LOT and seats me next to an old friend.

October 19, 2010

The computer is a boon and a bane

For those who fly on a plane

    It was a bad break,

    I made a mistake.

There’s none but myself that’s to blame

I had a problem checking in at the airport to fly home to Sioux City; the kiosk wanted to give me flight information for someone with the same last name.  At the ticket counter, the agent couldn’t find my itinerary. 

I haven’t made my own plane reservations since before the advent of the information age.  I used travel agents until doing so added cost to the ticket; after that Bethany made my travel arrangements.  Medicine took up too many hours.

This time I had Aliya walk me through the process.

I stood at the ticket counter while Aliya hunted for Wi-Fi service.

The ticket agent searched the computer several times.  One seat remained, and it would cost $1400. 

“Well,” I said, “It looks you have me over a barrel.  I’d like the ticket, but I’d like to speak to your supervisor.  And I’ll call my lawyer when I get home.”  My words were polite, respectful, and firm.  I made it clear I held no anger for ticket agents.

I stayed calm; we had arrived at the airport with plenty of time to spare.

The supervisor, Amanda, arrived.  Professional and smiling, she started punching computer keys.

Aliya located email; I pulled up my confirmation code, just as Amanda found that my return flight had been booked for November.  I looked at the message…sure enough, the mistake was mine.

“Operator error,” I said.  “I’ll own it.  I’m glad I wasn’t disrespectful.”

The supervisor did what she could.  I would have to fly first class.  The bite came down to $840.

I said, “That hurts.  It doesn’t hurt as much as $1400.  But I have no one to blame but myself, and it hurts enough to make me better at booking my reservations.  It’s a learning experience.”

We have negative emotions to teach us to deal better with the real world.

“Not all of my customers have been so polite about things,” Amanda said.

“Being polite,” I said, “has come much easier because I’m not in a hurry and because I’m in a good mood.”  I looked at Aliya and Bethany.  “And you can ask these guys, I’ve been in a good mood since February.  I made some changes.  I’ve been blogging about it.”

Bethany and Aliya nodded vigorously.  Bethany hastened to add, “Not religious.”

I said, “I even wrote a post about why I don’t write about religion.  Actually the worst part is that I won’t be able to sit with my family.”  But we went to security together.

First class brought new experiences for me: shorter line through security, priority seating, a bottle of water waiting by my seat, a decent turkey sandwich in flight.  Nice things, but they aren’t worth the extra expense to me.

The real perk was the fellow sitting next to me on the plane; I knew him from my Yale days.  We worked the radio station, WYBC, together.  He stayed in broadcasting and did well for himself.  I’d not seen him for forty years.  Catching up was a pleasure.

I believe in coincidence though sheer coincidence doesn’t happen often.   A person who decides to see signs can see signs everywhere, generally to reinforce a cosmic sense of purpose, usually unjustified.

But I keep my words soft and sweet, in case I have to eat them later.

Why is a free-lance artist like a locum tenens doctor?

October 18, 2010

The worst ones will lie and they’ll steal

I said to my bro at a meal

    But the great ones are pros    

   And bargain well I suppose

And everyone wins in the deal.

In the east for my wife’s family gathering, I called in New York on one my brothers and one of my sisters.

There are seven of us, we span 35 years and both coasts.  We are all intelligent and dyslexic with way  off-the-beaten-track senses of humor.  The other six (not me) possess great artistic talent.

You’ve seen my brother’s artwork in It’s a Bug’s Life, Monsters Inc, and Cars.  Currently he’s doing story boarding and working on his MFA in painting.

I talked to my brother about dealing with the locum tenens agencies (there are more than eighty; I’ve personally talked with about twenty-five), observing that the three parameters of professionalism, honesty, and flakiness shake out to a bell-shaped distribution.

“Listen,” he said, “Take it from me, and remember I’ve been free-lancing for decades, don’t deal with agencies, go directly to the employer.”

My brother should know; he sent out mailings of his portfolio on a regular basis for quite a while, and has first hand experience dealing with a dishonest agent.

I said, “I tried.  I called and mailed twenty health-care sites in central Nebraska and didn’t get a single call back.”

“Oh…Well they probably just want to deal with agencies,” he said.  “Then what you need to do is just deal with the best agencies.”

“That’s a great idea.” I said, “As part of this experience I wanted to deal with some good recruiters and some bad.  But if I was going to be doing this for very long I already know which agencies, there are two of them, that I’d go with.  The rest aren’t worth it.”

“How do you mean?”

“I’ve said yes to fifteen jobs so far and three have come through.  Sometimes it was poor communication, but I expect good communication from a recruiter, after all, that’s they do.  Sometimes they just out-and-out barefaced lied when they tried to do a bait-and-switch.”

He shuddered.

“And there’s this one recruiter,” I went on, “over the phone she sounds breathless and blond but she is a pro, an absolute professional.”  One of his eyebrows went up.  “Right after I agreed to a placement she had me specify six parameters for reimbursement…”  Both eyebrows went up.  “She wanted to know,” I explained, “How much I wanted for straight time, overtime, carrying a beeper, getting called, getting called in, and holidays.  Well, I had never thought of those things because no recruiter had ever asked me.”

“No?” my brother asked.

“Not one.  And I suspect that she’s a top-notch negotiator because she can get people to underestimate her.  She just got me a better deal than I asked for, and I’m pretty sure the folks she talked with would work with her again.  And that’s the mark of a good agent, getting the best deal for both parties.”