Archive for October, 2014

And after one day’s unemployment…

October 26, 2014

I drove a half-hour away
I had a great clinical day
Oh, what a tonic,
I ignored the electronic
And dictated what I had to say.

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 for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I did two short assignments in Petersburg, Alaska. On Sept 2, I turned in my 30 days’ notice.

On Monday this week I drove to Anthon, Iowa for a day of locum tenens work.

Over the weekend, in different social situations, two people approached me for medical advice, mostly having to do with medical care by other docs. For one I later wrote an email to the family, using physical examination buzzwords, expressing my concerns, and, hopefully, getting the patient into a neurologist in a timely fashion.

I made a phone call for the other patient, leaving a voice mail for their other doctor that I wasn’t officially on the case, I had observed certain things, and if the patient took Zoloft and Prozac, perhaps lorazepam could be discontinued?

Monday I left home early for Anthon, a quiet, prosperous but very small farm town. I’ll be working here from time to time for the next couple of months, in the complicated aftermath of a rural doctor’s personal tragedy.

The patient demographics stand in stark contrast to the Community Health Center. Most patients have insurance or jobs or are retired. No one has an accent. I did not see a single patient with major psychiatric illness all day.

Alcoholism, regretfully, stalks the clinical landscape as ruthlessly as everywhere. I applied my recently acquired Motivational Interviewing skills to the situation, and got at least a couple of people to think hard about their lifestyles. At one point, having gotten the initial three minutes of history, I asked very specific questions about the family history and got accused of being a psychic.

The ravages of past tobacco abuse permeated the day. I got the chance to interview one patient about experiences during World War II, and what it was like to grow up on a farm in the 20’s.

I said, as I have said before, “Weight loss in 21st century Iowa is NOT NORMAL and whatever else is wrong with you we have to investigate,”

I prescribed trazodone for depression, chronic pain, insomnia, and appetite loss, noting that the young doctor knows 20 drugs that will treat a disease but the old doctor knows one drug that will treat 20 diseases.

For the second time since I left the Community Health Center, the possibility of Parkinson’s came up.

I ate a leisurely lunch with the staff in the clinic’s tiny lunch room. We finished at 3:15, and I drove back to Sioux City.

I passed the whole day without getting behind in my documentation. The management spared me the learning curve of an apparently very bad Electronic Medical Record system, and I got to dictate my notes. Like in the old days when we had paper charts.

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Talking to recruiters.

October 26, 2014

For the what, the when and the where
For a job with inpatient care
I could compromise
On the salary size
But not things that I wouldn’t dare.

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 for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I used vacation time to do two short assignments in Petersburg, Alaska. I left the Community Health Center this month because of a troubled Electronic Medical Record (EMR) system.
I’m talking to more recruiters these days. When I tell them I’ve recently left a position I can hear an optimistic catch in their voices. Two days ago, I said, “I imagine you have to deal with a lot of rejection in your job.” Yes, she admitted, she does.
My ideal job, I tell the locums agencies, runs something like this (translation to follow): Hospitalist, 7 on/7 off, 12 hour AM shift, ER codes, intensivists on staff, no procedures, in Alaska.
Translation with explanation:
Hospitalists take care of patients sick enough to need hospital care. The hospitalist movement goes back no more than 10 years in this country. The US remains the only industrialized nation where outpatient doctors care for patients in the hospital. During residency in the 80’s, the older docs would point out that hospital work brought in money with no overhead aside from billing; but 20 years ago we started to look at the time we spent getting to and from the patient. A decade ago we looked hard at the inefficiency of drive time. Yet when, for a multitude of reasons, I took over my practice’s inpatient duties at one hospital, I found economies of movement which increased productivity with no shrinkage of patient contact time. And when I came to the Community Health Center, my contract specified I would work half-time as a hospitalist. That operation dropped adult inpatient work last December because the midnight-to-morning workload became unmanageable.
7 on/7 off refers to a work schedule of seven consecutive work days followed by one week of continuous rest. While an 84 hour work week sounds brutal, it affords the opportunity of going home in between stints.
12 hour AM shift is not really AM, but in the business it means 12 daylight hours, as opposed to the night-time hours. I really have paid my dues at this point and put in more than my share of sleepless nights. With the hospitalist movement has come the sub-genre of nocturnalist, so new that the position is sometimes called nocturnist; by whatever name, someone gets paid to take calls in the hospital all night.
ER codes means that the ER physician responds when a patient’s heart stops beating, to attempt resuscitation. Some docs, not me, enjoy the action, and compare it to “going to the Super Bowl”.
Intensivists on staff: With subspecialization, we now have doctors that do nothing but care for ICU patients. Sick enough to need an ICU means sick enough to needs a lot of doctor time. Trying to combine those patients with the less sick frequently means irreconcilable time conflicts.
No procedures recognizes that my skills at intubation, central line placement, and arterial line placement faded before the turn of the century.
In Alaska: self-explanatory.
Of course I expect to compromise on at least one of those parameters. I don’t demand my first choice, and so far I’ve said yes to three positions that haven’t happened. Yet I’ve learned how to have a good time anyway.

Caribou hunting on the other side of the date line

October 21, 2014

On an island where the bald eagles nest
So distant that East turns to West
For days, just a few,
I chased caribou
And had a well-deserved rest.

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 for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I used vacation time to do two short assignments in Petersburg, Alaska. I left the Community Health Center this month because of a troubled Electronic Medical Record (EMR) system.
I went caribou hunting on Adak Island, the southernmost of the Aleutians, and both the most western and most eastern permanently inhabited place in the US.
Russian enslavement of the Native Aleuts in the 1700’s and the subsequent famine depopulated Adak. When, during WWII, the Japanese invaded Attu and Kiska, at the eastern end of the Aleutians, Adak remained uninhabited. The population peaked at 100,000 for the campaign against the Japanese. During the Cold War, the Navy stationed 6,000 on Adak, and in the 60’s, introduced caribou to the island as an emergency food supply. With no predators, only hunting keeps the population in check.
The Navy abandoned the base about 20 years ago, tore down a lot of buildings, rendered safe the chemical and other weapons, and turned the island over, wholesale, to the Aleuts.
Today, the year round population has stabilized at about 300. Two jets a week land on a first-class runway; the TSA workers come in and leave on the jet. The island has two general stores, a cell phone shop, a self-service gas station (price per gallon $6.81,about twice what it costs at home), a division of the US Fish and Wildlife service, a school system with 5 teachers for 30 students, a restaurant, a post office, and a clinic staffed by a PA.
But housing for 6000 remains. A week’s visit gave me a taste of the mood of living in a ghost town: large numbers of uninhabited buildings, and a few energetic lively folks enjoying an island lifestyle with lousy weather. Everyone knows everyone except the tourists. Conversation and courtesy come easily.
Hunting, fishing, and birding tourism remains the main industry. The Aleut Native Corporation hopes to bring in commercial fishing facilities to compete with Dutch Harbor, and, eventually, a container ship dock to deal with the Northwest Passage and Transpolar routes. They already have the infrastructure.
Rain falls 340 days a year on Adak, and winds in January can exceed 100 MPH. Stuff made by humans rots and rusts, and becomes one with the island. No trees grow on Adak, but eagles frequent the streams where the salmon spawn, and walrus raise their young on a deserted corner.
In the airport on the way back to Anchorage, our party of 6 (two of us doctors) comprised the majority of those in the waiting lounge. I struck up a conversation with a young man who hadn’t come in on our plane. I asked if he’d been hunting.
No, he hadn’t, he’d been fishing. Commercial fishing, for halibut. Three days before, one of the crew members had started having asthma problems. The boat came to port but the crew member died shortly after arriving at the clinic.
The young man wore a haunted look. I didn’t know what to say.
I didn’t reveal my occupation.

Protected: Unemployed but not out of work

October 8, 2014

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Going walkabout again

October 7, 2014

The thirty days that they require

Has now come right past the wire

I think that it’s fitting,

Not quite that I’m quitting,

I’m hoping someday for re-hire

 

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 for adventures working in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center.  I did two short assignments in Petersburg, Alaska.  On Sept 2, I turned in my 30 days’ notice.

I finished up my most recent job this week.

I liked the position, I had wonderful nursing support, and our new CEO has gone a long way to improve the problems that her predecessor brought on.

I got the chance to speak a lot of Spanish. Opening up my patient panel brought in a flood of pediatrics and young people.

I got to see pathology I wouldn’t get to see elsewhere, because of our patient population. I took care of many schizophrenics, with a high prevalence of Type I Diabetes.  East and West Africans came with a whole range of unusual problems including TB and its late consequences.  Rarely a week went by when I didn’t declare, “Weight loss in Iowa in the 21st century is NOT NORMAL.”

I also got a waiver to prescribe buprenorphine, a narcotic used to treat narcotics addicts. By Federal law, a doctor can’t get that credential without 10 hours of Continuing Medical Education and taking a test.

I learned a lot about narcotics addiction by getting my name on the national list. Opiate withdrawal turns out to be a lot worse than I’d thought, and takes weeks to conclude.  I developed my own mnemonic, DANDY LIPPS (dysphoria, aching, nasal discharge, diarrhea, yawning, lacrimation, insomnia, piloerection, pupillary dilatation, salivation) to remember the features.  Diarrhea, sleeplessness, and pupillary dilatation resolve after all the other symptoms have disappeared.

I learned other lessons about the ugly process of addiction. My own narcotics prescription habits have gone from conservative to stingy to the point where I baulked at 15 hydrocodone for a patient with well documented kidney stones.

The corporate subculture of functional, mission-driven dynamics and support made the work day go well.

Why, if my job had so many positives, would I want to leave?

The answer comes down to one item, the electronic medical record (EMR) system. Poorly designed and badly installed, I found it barely tolerable till June.  The vendor sent us an update without beta-testing, and the system slowed down from snail to glacial.  Clicking on a button would not bring a response in less than 20 seconds.  Clicking on a particular, popular button would guarantee a freeze-up that could only be fixed by the System Administrator.  I found myself spending more than 8 hours weekly watching an unresponsive screen.

One day the system kicked me off 11 times, with each sign-on costing an average of 5 minutes. At the end, I finished my documentations and started in on the queue of 35 messages from the Billing Department.  The first one took 14 minutes to complete, most of it involving an hourglass that didn’t seem to move.

I gave my 30 days’ notice and I did my best to burn no bridges. I left eligible for rehire, on such good terms that I’ll cover the 12/25 holiday.

In the meantime, I’m going walkabout again.

Another last week

October 5, 2014

Quite early to work I did sneak
To start when no one would speak
I will sing and I’ll praise
These last final days
And be done at the end of the week

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 for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I did two short assignments in Petersburg, Alaska. On Sept 2, I turned in my 30 days’ notice.
My last week with the Community Health Center started with a really fantastic Monday. Away from the clinic for ten days for a hunting vacation, I looked forward to patient contact, but dreaded the crunch that comes from being away. So I arrived an hour early, and attacked the 35 items that had accumulated on my electronic desk top, mostly expected normal lab and x-ray.
Three thyroid items came unexpectedly normal, a welcome set of results for a family with no resources and no insurance.
Four items had to do with one of my buprenorphine patients. I had to get a special license to be able to prescribe this narcotic to narcotics addicts, and this particular patient had done well with counselling and meetings for 7 months. Despite warnings to the contrary, the quartet of ER documents confirmed that the patient took an off-the-street benzodiazepine (the drug class that includes Xanax, Valium, Librium, alprazolam, lorazepam and diazepam) and lost the will to breathe, which in this case necessitated CPR and an ICU admission.
Two of my other buprenorphine patients came; they have done well with the medication and watching them maintain jobs and families encourages me. That medication, however, like any other in my profession, lacks 100% efficacy. In fact, if I hit 20% with this particular disease state I count myself lucky. No drug does any better. I had to arrange for subsequent care for both.
No-shows kept my patient flow well within reasonable limits; I kept up with my documentation along with the steady influx of results and reports that have to be personally reviewed by the doctor. Also the numerous emails that accompany the end of employment.
I flew down the stairs to Human Resources to sign papers and learn about my benefits. I spent most of my exit interview talking about the stuff I love about my job.
Then I enjoyed a rare luxury: lunch. I ate my sandwich, smoked salmon salad with fresh basil lovingly prepared by my wife. For twenty minutes I savored the goodness without trying to work at the same time.
One of my schizophrenic patients came in for the monthly Haldol injection, and expressed sadness that I’d be leaving; we share an interest in history and frequently we surprise each other with our details. Well children alternated with diabetics, depressives, and hypertensives, and the afternoon slipped into evening.
And just when I started to wallow in how reasonably the day had gone, to barely start to wonder about my decision to leave, the computer froze, and I remembered why I turned in my 30 day notice 27 days before. I fumed. I muttered bad Navajo words under my breath. I had fantasies of throwing my computer out the window.
I left the office before 800PM to go to the gym, with only 5 documents left undone.