Archive for July, 2013

Not getting the offer I said yes to.

July 28, 2013

To the recruiter I didn’t say ‘no’

I’ve decided that I want to go

Life can be cush

But in Alaska’s there’s bush

And salmon, mosquitoes, and snow.

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

I said ‘yes’ to a recruiter.

It took a good deal of thought, but I remembered what a great time I had doing locum tenens (temporary doctoring) work.  I looked at the number of hours of Paid Time Off (=vacation) and I decided I could go back to Alaska for a couple of weeks.

I had worked with that recruiter before, who has shown incredible skills as a negotiator and who made me specify 5 different parameters of how much I wanted to get paid, and has never failed to bring a position in for me.

This particular gig boasts a 40 work week with no nights and no weekends in the Alaskan bush less than 2 air hours from surgical backup.  It sounded perfect.  All things in context, all things in comparison: it looked like a vacation.

(The bush is anywhere in Alaska that can only be reached by plane, boat, or snow machine.  I like the bush but my zone of comfort stops as soon as it takes more than two air hours to get to the patient to surgery.)

I fantasized about fishing the river for salmon in August and visiting friends who moved to Alaska after residency.  I looked up the village on Googlemaps and Wikipedia.  The Natives have their language intact, but the job might have been for the non-Natives.

I thought about that part.  Native health facilities generally don’t treat non-Natives except in cases of emergency (other exceptions include active duty military and their dependents), but non-Natives play an important part in rural Alaska.  Any place with a large enough non-Native population will need a medical facility.

My mood improved while I thought about going on a new adventure.  I filled out a vacation slip, and I walked with a bounce in my step.  Bethany, accurately, said I quit whining.

The recruiter called me Friday to say that three other docs, all full timers, had put in for the job.  In all likelihood it will not go to me.

But during that entire euphoric year of walkabout I almost never got my first choice, and I still had a great time.  I’m starting to look into other opportunities, and I’ve got my time frame narrowed down, to the last part of August.

No matter what I plan, it won’t turn out the way I planned.  I look forward to the surprise.

Let’s see what happens.

July 27, 2013

A matter of prognostic projection

When it comes to a diagnostic question

My pain management skills

Involve very few pills

And no longer my Enbrel injection

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

During my senior year of medical school I arranged to get credit for an elective rotation in acupuncture in January of 1979.  I studied under a very smart non-Asian internist for a month, and learned the vocabulary and the rudiments.

Before I had passed any Boards or actually obtained a license, I did acupuncture on a friend in a time crunch.  I applied a needle in each shin, close to the knee (the name of the point is Su Zan Li, but its nickname means three villages).  He responded well, and worked with tremendous efficiency for the next 9 days, turning out top-notch work.  The bottom dropped out of his energy three days later, and he slept for the next two days.

In retrospect, I had precipitated a hypomanic episode; his bipolarity would not be diagnosed for many years.  Nor did I realize the enormity of the power of those two needles for decades.

High-quality research with acupuncture showed mixed results.  A study published in a major journal demonstrated very good results in treatment of the most severe alcoholics (regretfully, the study didn’t detail exactly where needles went nor how they were placed).  Another, published in JAMA, showed acupuncture and sham acupuncture equivalent in the treatment of migraine.  Many docs point to that study and assert acupuncture has no validity; I look at the same data and conclude that you don’t have to be much of an acupuncturist to treat migraine; put a half-dozen needles anywhere you want and not very deep, on a regular basis and at the end of a year the patient will have half the migraines he/she used to.

I went to my acupuncturist today for a session because I’ve been off Enbrel for three weeks.  My sacroiliac joints haven’t fused despite my age, leading my rheumatologist to question the diagnosis of ankylosing spondylitis.  He would like to see if my sed rate (ESR) and my C-reactive protein (CRP) go up in the absence of therapy.

I can hope for a misdiagnosis, or for news that my disease has burnt itself out, but as the days go by the pain in my spine grows.  I’m now relying on the pain management skills I developed between 1967 and 2000, when I got my first injection.

I can do a lot of things to bring down the level of pain a notch or two; I can’t do anything to make the pain go away completely.    When I walked away from the acupuncturist/chiropractor’s office the pain between my shoulder blades had faded by about two-thirds, and I could sneeze without grunting.

Now I have to work on my sleep pattern.

Low quality research, infectious mononucleosis, and clinical experience.

July 25, 2013


People and doctors think twice

For a test that’s ten times the price

When for a positive test

The treatment is rest

And the quick, easy lab seems so nice. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

Eight viruses belong to the human herpesvirus family.  Herpes 1 brings cold sores or fever blisters; herpes 2 gives the recurrent STD blisters.  Herpes 3 is the Varicella-Zoster virus and gives rise to chickenpox and shingles.  The Epstein-Barr virus belongs to the same family, and causes infectious mononucleosis, or mono.

My personal experience with mono came in January of 1969, with a sore throat, nausea, loss of appetite and headache.  I dragged myself to the Department of University Health, got a blood test and went to sleep for the next week and dragged myself back.  The doctor declared I did not have mono.

I didn’t get better, and 8 weeks later dragged myself to a different doctor in the same building who announced the diagnosis of mono.  No, I replied, the other doctor told me the test came up negative.  Well, he said, look at the lab slip.

Sure enough, someone had written the word POSITIVE on the yellow 3×5 lab slip.

They used the Beef Heterophile Agglutination test back then; the updated version carries the trade name MonoSpot.

Twenty percent of the population cannot make the chemical that causes the reaction; we now have sophisticated confirmatory tests that can distinguish between mono acute, chronic, recent past, distant past, and not mono.  But it costs ten times more than the Monospot.

Chronic mono happens but not very often; those patients who get it have other problems with their immune systems.

I had to explain those things to a patient Wednesday who kept having problems with recurrent severe sore throats (and who gave me permission to include a good deal more information than I have) for years.

The standard treatment for mono boils down to six weeks of bed rest.  More common non-standard treatment includes steroids.

No one would use the word brilliant to refer to the research done last century on the use of Tagamet (cimetidine) in mono.  The patients in each arm numbered in the few dozen.  The publication did not mention the dose.

Within 5 years of reading the article I had personally treated more mono patients with cimetidine than had been in the original study.  After 10 years, I could tell my patients my clinical experience: 25% of mono patients bounce back dramatically under Tagamet in less than 24 hours, 50% bounce back but less dramatically in less than a week, and 25% do not respond.

The patient considered the costs of the lab tests and the cost of the generic cimetidine, and decided for treatment.

I’ll know the outcome next week.

Weird things with pills

July 21, 2013

Some people, while looking for thrills,

Aren’t choosy when it comes to their pills

They get stoned and then drunk,

Or droned and then stunk,

And face horrible hospital bills.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

People do weird things with drugs.

I won’t say where or when this happened.  The patient in the ER claimed to have confused pills (an antidepressant) prescribed for someone else with a common analgesic (ibuprofen), supposedly for joint pains.

The incident happened in the context of partying with friends the day before.  As the gentle interviewing process continued, the number of recreational drugs ingested doubled, then quadrupled.  I didn’t bother to ask about dose; no one can count after they’re high.  Some of those recreational chemicals were legal, some were illegal, some were legal for someone else, and I didn’t want to know who.

Med school trained me to be a doctor, not a judge; HIPAA mandated that any information I get from a patient can’t be revealed to anyone else without their consent, not even to the police.  In fact, if I started to report all the illegal drugs my patients use, I wouldn’t have time to attend to sore throats and runny noses.

But the patient’s story kept changing, not surprising given the degree of intoxication.  The other party in the exam room kept showing me the prescription bottle and saying, “You can really see how someone could make that mistake, can’t you?”

No, I couldn’t.  And I said so.

And as hours passed, the patient’s behavior got more and more bizarre, and less and less congruent with an antidepressant overdose the day before.  Eventually, the patient had a bed in the ICU, nurses had bruises, police arrived and applied handcuffs, large doses of tranquilizers found their way in the bloodstream, and I had spoken with the Clerk of the Court to get a 48-hour hold.

Less than 24 hours later I had the chance to discuss the case with a couple of clinical pharmacists.  We looked at the drug involved and the length of time it takes to clear from the system and the physical findings.  We agreed that the two people had left out large parts of the truth.  I had to admit I had looked at the antidepressant bottle but hadn’t looked at the pills.  Could I vouch that the bottle contained the antidepressant in question?

No, I couldn’t.

For the most part, patients tell me the truth as they see it.  Sometimes they just lie.  The more I thought about it the less I wanted to take the story at face value.  After all, I find it more likely that someone who had just had a “couple” of beers, an unknown amount of marijuana, and a dubious dose of amphetamine would take something else on purpose rather than by accident.

Following Poison Control’s explicit directions, I treated the patient, let time take its course, and watched the patient improve.