Archive for October, 2013

Saying no, and not getting my first choice.

October 20, 2013

I think I’ll take off for a week.

Perhaps a large elk I will seek.

Or I’ll take me a drive

For ten days or five

To the Front Range, out near Pike’s Peak.

 

SYNOPSIS:  I’m a family physician from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, worked in out-of-the-way places from New Zealand to Barrow, Alaska.  Now I work part-time at a Community Health Center, on average 54 hours a week.  Just back from a two-week working vacation in Petersburg, Alaska, and a week Continuing Medical Education in San Diego.

 

Usually I plan ahead better than this.

About three weeks ago I decided I wanted to go elk hunting during the first week of November, I contacted an outfitter, and, at the same time, requested to be off the schedule for that time period.  Few outfitters would consider such short notice hunts, but I know one who would.  Three days into the negotiations I read his Facebook post that he’d gone lion hunting, planning a return in two weeks.  I performed a basic game theory analysis and decided I’d better make alternate plans, especially because I’ve learned the importance of time off.  I started thinking about taking some Continuing Medical Education time (I have 48 hours left in my account), and I went looking for a course in a place where I have family and friends and came up with a 5 day Board Review course in Denver.

I haven’t actually paid for the course.  Imagine my surprise when a locums recruiter contacted me at the beginning of last week to see if I wanted to work for one week in Alaska.

I thought about it for a day and a half and replied that I wanted details.

The only reason I can pronounce the name of the place is because I already speak one Athabascan language.  I went to Wikipedia and found some really interesting history; the clinic serves the Native population.  The village has air and water access but no road leads there.

I considered it enough that I asked that key business question, How much?

The figure came out so low that it shocked me.  When I do locums work, I frequently say that it’s not about the money.  Such a price could pass for an insult.  But I inhaled and asked if the situation carried profound humanitarian implications.  I would work below industry minimum if a colleague had a life cycle event or faced a crisis.

I casually went back to my email while I awaited the call.

The clinic staffs exclusively with locums, and had a one week coverage hiatus.  The recruiter gave me a counter offer below my bottom line, saying that the firm didn’t want to lose money on the deal.  I replied that I didn’t either, and asked her to keep me in mind for future assignments.

My first choice would have been the elk hunt, but experience has shown me I rarely get my first choice, and I generally finish happier when I don’t.

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Taking the bump: think it through

October 5, 2013

We had seats on an overbooked flight.

Would we take a bump?  Well, we might.

It depends on the price.

But the agent was nice,

And we got home just before night.

SYNOPSIS:  I’m a family physician from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, worked in out-of-the-way places from New Zealand to Barrow, Alaska.  Now I work part-time at a Community Health Center, meaning that I average 54 hours a week.  I just got back from a two-week working vacation in Petersburg, Alaska, and an educational convention in San Diego.

I recently took a non-credit course in Game Theory; it had major overlaps with chaos theory and economics, and a few in physics.  If I can summarize 18 hours of lectures in a one sentence: think things through.

On our way back from San Diego, the airline announced an overbooking situation and offered to pay people to rebook their flights at a later time.  Usually I don’t have that kind of flexibility, but on this occasion we had arranged travel on a Saturday, and I didn’t have clinical duties till Monday.  For the first time, ever, I could afford to take the bump.

And I could apply my new-found game theory skills.

Most other offers of cash-for-getting-bumped have come while travelling on a Sunday and have gone begging at $400 a head.  In this case,.  I decided that probably a lot of other people had flexibility and would be more willing to take the money, so that the chance of getting a large sum would go down

I hit the ticket counter before anyone else, and offered up my seat in the spirit of cooperation and greed, to the tune of $200 a head, paltry in comparison to past offers.

While I stood there, another pair of passengers came to vie for the prize.

The agent booked us on a later flight going through Phoenix rather than Houston, avoiding some bad weather, cutting the total flight time by an hour, shaving another hour off a layover, thus getting us into Omaha 2 hours ahead of schedule.

I declared, to the agent, the classic win-win situation.

Yet we still boarded the plane with disappointment in our hearts that our original itinerary would be followed.

Five minutes before scheduled take-off the flight attendant had us leave the plane; something to do with a loose seat bolt elsewhere.  We strode across the airport to a different airline’s gate, and in a few hours touched down in Omaha, richer and sooner than expected.

Just one more example of being pleased to not get our first choice.

Scenes from a convention

October 3, 2013

I came to get learning specific

In San Diego, out by the Pacific.

I took lots of notes

and paraphrased quotes

But the coincidences were really terrific.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska and an educational trip to the AAFP Scientific Assembly in San Diego.

I walk into the San Diego Convention Center, my third time here for the American Academy of Family Practice Annual Scientific Assembly.  It still smells like San Diego, the ocean, the palms, the sea.  I stride from one end of the Center to the other, counting the steps and making note of the time, further than my commute from my cottage to the Medical Center in Petersburg, Alaska.

I have the handouts in my backpack.  In years past the book swelled from a couple of hundred pages to two thick binders.  Now they exist on a simple thumb drive.  The same backpack carries my iPad and its associated keyboard.  Last time I came I used a smaller keyboard and my Palm to take notes.  Light and easy to carry, it could beam but not email data.

Now instead of a cell phone I have a smart phone, and I download an app that gives me the course listings with times and places and lets me enter my CME (continuing medical education) credits as they happen.  When I first came to the AAFP convention the words smart phone, Wi-Fi, download, and app did not exist; wireless meant radio, usually two-way, in stodgy British, and the word router denoted an electric wood-working tool.  If you said high-speed net service you might have been laughed at but if you used the term repeatedly you would probably get locked up.

The Exhibition Hall stretches for a cavernous quarter mile inside the Convention Center.  Big Pharma, now barred by law from giving out toys, flashlights, pens, or note pads as advertising, concentrates on pitching drugs.  My Community Health Center patients, half of whom have no resources and no money, can’t afford the new drugs.  But I stop at the Lilly booth and thank the reps for their company’s generosity; they give my facility an enormous quantity of insulin for free.

The lecture on smoking cessation strategies features lackluster content and a passionless presenter.  My attention wanders, I yawn, I try to keep myself awake doing carpal tunnel stretches.  I nod off, then I fire up my iPad and read my email.  I look around and see other attendees either with eyes closed or with their faces illuminated by their portable screens.  No one pays attention.  Five minutes from the end of class I pull out my Droid to try to enter my CME credits, and find I can’t do it without a major workaround.

Even if Big Pharma can’t give us advertising freebies, they can serve us fantastic meals and hire gifted teachers to lecture us.  While I munch an outsized turkey sandwich I marvel at the teaching effectiveness of an FP from Pennsylvania.  She speaks with dynamics and enthusiasm and imparts information I’ll retain after the drug comes off patent.  Except she never mentions a new drug or even an old drug; she talks about urine sugar reabsorbtion and diabetes.

Bethany and I sit down to lunch the next day with a young doc in the Indian Health Service; she nurses her infant while we talk.  At the end I challenge her to keep track of her hours for two weeks, use that number to figure out how much she’s getting per hour and compare that rate to locum tenens.

I run into a doc I knew in residency; I run into him six times more in the course of four days.  Then I run into a doc who now teaches in that program.  In the hotel elevator I run into two more FPs who finished the program and still work in Casper.

One evening Bethany and I dine with a doctor who still works at the Practice Formerly Known As Mine.  At the end of the meal we stroll along the marina.  We come to the Vibrant Curiosity, the world’s 60th largest yacht.  We had seen the 5 story wonder coming up Wrangell Narrows while we were in Petersburg.  We make jokes about how the owner must be following us and the next thing you know it will come cruising up Perry Creek.

True coincidence occurs but rarely.  But I don’t know what it all means.

Minor surgery and its complications

October 1, 2013

What put my time into a crunch,

Was a biopsy, not a shave, but a punch.

Then the red flow,

Just wouldn’t slow.

He lost some blood, yes, a bunch.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska and an educational trip to the AAFP Scientific Assembly in San Diego.

The skin lesion cries out for a punch biopsy.  The size of a business card, it sprawls across the top of the foot.  I spotted it on a routine diabetic foot check.  It hits all the ABCDE alarm criteria: Assymetric, Border (irregular), Color (inhomogeneous), Diameter (more than 6 mm by far), and Evolution (patient had it for years but it started changing in the last couple of months.

I warn the patient about the possibility of infection, bleeding, pain, and the certainty of scar; along with the possibility of catching a cancer early.

When I had the infrastructure set up, with materiel handy, I could do the procedure in 4 minutes.  Now the nurse and I put together the biopsy punch, suture, needle driver, anesthetic, and scissors.

Alcohol, local anesthetic, betadine skin prep.  The biopsy punch is a circular knife the size of a ball point pen end, the surgical equivalent of a cookie cutter.  I take a plug of skin near the edge, including part of a distressingly black bump.

I would never believe that much blood could come out of a 4mm hole.  It doesn’t spurt like an artery, it just flows.  In all the time I have warned patients of bleeding, such a complication has never occurred.

(Once the patient had an infection after the punch removed the entire, 1mm malignant melanoma.)

The blood streams while I work to try to find the source.  In short order I recruit a second nurse, call in two hemostats and an absorbable suture, don my headlamp and remove my glasses.  Five minutes of local pressure doesn’t slow the flow, but pressure 8 mm closer to the toes gives me a dry field.  I clamp an apparent bleeder and throw a noose of absorbable suture around it, and for a moment the bleeding stops.

It starts again.

Forty minutes later I put a deep vertical mattress stitch in, pull it tight, and the red flow disappears, leaving me 4 patients behind, sweating and exhausted.

I confine my operative ventures to the skin, nothing deeper, because I can handle those complications.