Archive for December, 2014

Flu season and I got it, too.

December 30, 2014

Not sure on what I should do,

My temperature serves as my cue

And another good reason

At this time, it’s the season

To suspect that I’ve gotten the flu.

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, where I worked for 3 years and left because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.

Shaking chills didn’t set in till after I left the clinic.

I hadn’t felt well most of the day, with a cough and runny nose and violent sneezes.  But I kept track of my temp, and no matter how badly I felt, it never strayed north of 99.3.

Despite the muscle aches, headache, and loss of appetite, I thoroughly enjoyed the morning.  I got to treat anxiety that bore no relation to alcoholism or other self-defeating behaviors.  People came to me with colds and coughs; I listened to what they said and I listened to what they didn’t say.  I got to treat a case of pneumonia appropriately with antibiotics, and I avoided antibiotics for those who didn’t need them.

Although snowy roads and the consequent crawling traffic got me to the rural clinic 30 minutes late, patient flow proceeded well.  The nurse and I stepped into the bitter cold about 11:00AM to walk the 30 yards to the nursing home.

I napped after my midday sandwich, but I slept longer than my usual 18 minute power nap.  The original schedule listed one patient after lunch, but the update brought one at 1:45 and another at 2:30.

I didn’t feel my best and I didn’t mind that more patients came.  In fact I reveled in my work, though between patients and dictations I kept asking the nurse to check my temperature.

I would have left if I had had a fever.

The final patient tested positive for influenza A.  I prescribed oseltamivir, called in my last dictation as my voice plunged into the subwoofer range, and accepted the nurse’s proffered Tylenol.

I thanked the staff for a great day; I had enjoyed myself immensely, and we agreed we’d done a lot of people a lot of good.  We went over the patients we’d seen, the stubborn headache relieved, the back pain addressed, the surprising results of a urine drug screen.

I slipped my fleece jacket over my white coat and stepped out into the bright afternoon sunshine and single digit temperature.

But I shivered violently as I pulled onto the state highway; I had a good hunch I’d contracted influenza despite being on preventative oseltamivir.

Forty minutes later, as soon as I got home, I crawled into bed.  By then my temp had gotten to 100.5; barely a fever but enough to make me feel lousy.

Next morning my doctor confirmed my suspicions, bumped my dose of the anti-viral, added in a second anti-viral, and advised Is hydrate well.

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2014 in review

December 29, 2014

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 9,400 times in 2014. If it were a concert at Sydney Opera House, it would take about 3 sold-out performances for that many people to see it.

Click here to see the complete report.

Not confronting a smoker

December 28, 2014

On the edge of a change, on the brink,

I might bring a person to think

About why they’re broke,

Or continue to smoke,

If into the cold they must slink

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, where I worked for 3 years.  I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.

On my way into a drug store to pick up melatonin for my upcoming trip, I saw a young, depressed-looking woman leaning against the brick wall of the adjoining building, smoking a cigarette next to the employee entrance of a health care establishment, and I faced a dilemma.

I could something or I could say nothing.

If I said something, I could say any of the things she’s already heard, but, as her continued tobacco use showed, those things hadn’t dissuaded her.  I could point out that the lungs of a smoker beat every other place on earth for radioactivity (including the hospital basement in Chernobyl where the radioactive clothes were dumped and where they remain) except a nuclear power plant; she probably hadn’t heard that.  Or I could whip out my calculator and point out how much money she burns a year.

I briefly considered saying nothing, but only briefly.  Not speaking out would go against my very identity.  Tobacco killed too many members of my family.

Whatever I would say I would have to use a minimum number of words.

I didn’t try to show her the wrongness of her actions.  I didn’t ask her, on a scale of one to ten, how ready was she to quit.

I exited the car.  “So, how’s that smoking thing working out for you?” I asked.

Her joyless face blossomed into a sardonic smile.  “It’s OK,” she said.

I said nothing more.  I can hope I made her think about the problem, I can hope I made a difference, I can hope I did the right thing.  But I cannot know.

I can regard the irony of a health care worker smoking, and I can wonder about the drama.

Christmas call and prepping for a new assignment

December 25, 2014

I start out this Christmas on call
As I’m trying to make sense of it all
With the unknown I’m flirtin’,
Cause I embrace the uncertain
While I walk the hospital hall.

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, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.
It’s Christmas and I have call as I have had since 1979. But, fundamentally, the word carries different meaning now than it did December 2, 2013 when my group limited our inpatient responsibilities to infants and children.
Still, I printed out our hospital census and found the diagnoses of detox, alcoholic encephalopathy, and OD at the top of the list, along with COPD, respiratory failure, dehydration and urinary tract infection. I ignored those patients whom the hospitalists care for and went up to Newborn Nursery; I examined the patient and used all of my Oroomo vocabulary (less than 10 words) talking with the mother.
I read the paper in the doctors’ lounge, and went to the other hospital. I talked with another FP. I listened while she discussed her practice and her children, and then I related my upcoming plans and how I learned to live with uncertainty.
I refuse to believe in my next job until I get my tickets; those arrived two days ago. So, except in the case of bad weather, I leave Iowa on New Year’s Day and arrive in Nome, Alaska the day afterwards. I can recover from jet lag for a couple of days and start orientation about 3 days later.
I read the Wikipedia article on my destination. I follow the blog from a doc who works there.
Yesterday I started putting together my gear; long underwear comes first. I have Arctic-grade overalls, mittens, and parka.
I dug out the aluminum wok I got at a garage sale during med school. It served me well in my 4th year, when I moved 6 times in 6 months. I moved less stuff every time, but that small, light, handy wok survived the odyssey.
Much remains to be purchased and even more assembled.
On this trip I would like to acquire more Inupiaq language than just vocabulary, and I contacted Rosetta Stone about a product they developed 7 years ago.
But throughout the day the tingling of anticipation coursed through my veins, more anticipation than just the holiday season brings. I wonder about the things I’ll see and the people I’ll meet. I enjoy the delicious sense of not knowing. If I knew, I couldn’t have any surprises. And I look forward to them.
After all, I’ve learned to live with uncertainty.

A very good colleague faces a groundless lawsuit

December 22, 2014

Perhaps one doctor should shoot

One lawyer, a scoundrel and brute

If there cannot be found

Any cause or a ground

For filing a malpractice suit.

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, where I worked for 3 years.  I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m working a bit with one of the rural docs, and getting ready for another job in Alaska.

In the hospital for paperwork, I ran into a subspecialist colleague.  I gave a brief case presentation, and asked for advice.

We call such interactions “curbside consults,” and we have etiquette and protocol for them.  If the consultant asks to see the patient, we make arrangements.  If not, the specialist’s name remains absent from the dictation.  The interchange of knowledge adds value to patient care without adding cost, and the social interaction reinforces the personal bonds between physicians.

Some consultants give more cogent answers than others.  In this case, the solid response took less than a minute, and made me an incrementally better physician.

At the end, my friend and colleague said, “I’m being sued.”

I have known this doc for close to 3 decades.  During my Winnebago days, years before our first face-to-face meeting, I could count on acceptance of my patient transfers, in the face of uncertain payment by the IHS and despite life-threatening illness.   For years I have seen moribund patients reprieved from death, sick patients restored to health, apparently well patients kept in good health and reassured, and early stage cancers detected and promptly treated.  I received excellent advice, and never, not once, saw a mistake.  As near as I can tell, this is one of the few doctors who never has an off day.

I asked, “Is this the first time you’ve been sued?”

The answer:  Yes.  The details: completely bogus.  The patient failed to promptly take initial advice, went elsewhere, got the same advice and complied.

No lawyer in town would take such a case.  We agreed that an ambulance chaser might be at work.  (By law, an attorney might advertise, but may not directly solicit a client who did not contact them first.)

My heart sank in sympathy.  I talked about my one malpractice suit, where the lawyer named every doctor with a name on the chart, including the radiologist who diagnosed the spread of the cancer and the pathologist who did the autopsy.  All but one of those physicians, including me, got dropped from the suit before the trial.  Thus I could give reassurance.

I have a lawyer friend, who justified his profession’s ability to sue anyone for anything by saying, “At least the only thing we’re taking away is money, and that can always be replaced.”

A malpractice lawsuit takes away much more than money.  It sullies a reputation.  It sucks time and energy that should be constructively applied to patient care.  For the rest of that doctor’s career, he or she will always have to answer “yes” if asked, “Have you ever been sued?” and have to give details.

Worse, doctors start to question their own judgment.

“You know,” I said, “All it would take would be one disgruntled doctor killing one scum bag lawyer.  But we never do that, instead we kill ourselves.”

A lot of doctors, having met with the first lawsuit of their careers, choose to retire.  My colleague could easily decide that the straw of the lawsuit, added to the large and increasing regulatory burden in the face of decreasing reimbursement, has broken the camel’s back.

I would miss the clinical competence and the friendship.

Jury Duty: Avoided. The truth sets me free

December 21, 2014

The sentence given to me

Ten days or a large fee

A minor infraction

But now, no retraction

And the truth indeed set me free

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, where I worked for 3 years.  I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.

I didn’t own a car till after I graduated from medical school.  In the late 60’s and through the 70’s, I answered my transportation needs on a local level with a bicycle and on a larger scale with hitchhiking.  I ran more risks than I should have, and I don’t want my children to learn what I learned.  But I had loads of fun.

In March 1970 a driver dropped me at the intersection of Kansas 177 and Interstate 80, east of Junction City, Kansas.  Another long hair stood at the same on ramp.  We shook hands.  He offered me some honey, and we shared a snack as we stood well off the pavement, next to some rocks.  I talked about the limestone and explained the flint nodules.  Then the Geary County Sheriff’s deputy showed up and arrested us both.  Before sunset, I had been convicted of being an illegal pedestrian, and sentenced to $100 or 10 days.

Since then the law has changed, the Supreme Court finding that sort of sentence discriminatory against the poor, and now the convicted can’t buy their way out of jail.

I didn’t have the $100 at the time, and, besides, I love adventures and I’d never spent time behind bars before.  I got to hang out with 4 other guys, charged with, variously, bad checks, breaking and entering, murder, and illegal pedestrian.

Terrible weather hit the evening of my incarceration, white-out blizzard conditions.  Four days later when the weather broke, the judge summoned me back to court.  He looked exhausted.  My mother had been calling him at home, day and night.  He told me to get on the Greyhound Bus and leave the county.

I don’t much like Greyhound Buses and my feelings for Geary County in general and Junction City in particular have mellowed but little since then.

Now when I fill out a credential application, such those completed for my Pennsylvania license or for my upcoming assignment to Nome, I say “I spent 4 days in jail for being an illegal pedestrian, my real crime was probably having a pony tail in 1970 in Kansas.”

More than forty years later, summoned to jury duty when I had no work scheduled till Friday, the judge promised we’d be out, at the latest, tomorrow afternoon.

The judge, smiling and professional, asked preliminary questions.  He if we’d been arrested.  Mine was the only hand that went up.

Laughter rang in the court room when I said illegal pedestrian, and came louder when I said 4 days in jail.

Then the judge cleared the courtroom, and called me back in 10 minutes later.

I admitted my biases, both for and against the defendant.  While I have a deep mistrust of law enforcement, I said, because of my work I have an even deeper trust of lab results.

Then he asked if I believed that people get stopped for Driving While Black.  Yes, I said, I did; it has happened several times to one of my daughters because she got all the kinky hair genes from my wife and me.

Three and a half hours after I entered the courthouse, I walked out into the bitter cold.

Speaking the truth might have set me free. It at least got me out of jury duty, but it took all morning.

A breakfast meeting with a new colleague

December 13, 2014

A respite that’s every so fleeting

From the diseases we find ourselves treating

I sat down to talk

With a colleague, a doc

An informal at-breakfast meeting

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, where I worked for 3 years.  I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.

During my time in Barrow, Alaska, the doctors met every morning from 8:00AM to 9:00AM.  We reviewed admissions, evacuations, problem patients, and interesting cases.  The agenda rotated around the table, everyone had a chance to talk and everyone had something to say.  Each time I left the table a better doctor than when I sat down.

When I returned home after my walkabout year, I fell in with a couple of colleagues who had also worked in Barrow.  We breakfasted together once or twice a month, and the informal meeting always made us better doctors.  Neither of those docs works in town now.

I breakfasted with a new colleague, Board certified in both Psychiatry and Family Practice.  I got to tell her about the Old Days, when med schools actively excluded women, doctors could hit patients but only when they deserved it, laparoscopic surgery existed exclusively as an idea in my head, and the diagnosing primary care doctor earned a lot of money as the surgical assistant.

I told her about the funeral I’d been to earlier in the week (see the previous post), and the amazing surgeon I’d had the privilege to know and work with.

Over semi-scrambled eggs with mushrooms, onions, and smoked turkey, I laughed with her at her vivid description of her embattled clinical situation.  As with most who work in community health and/or with the mentally ill, she faces an impossible situation of inadequate resources and challenging patients.  She compared it to a battlefield front-line aid station equipped only with eye-patches.

We discussed obstetrics, how much we both enjoyed it and how much I enjoyed stopping.  We agreed that the feeling in the room immediately after a birth carries an evanescent sense of perfection not found elsewhere in this life.

I got to talk about how I learned how not to interrupt the flow of feminine energy in the process of a delivery.  I have found this concept nebulous and difficult to teach and embarrassing to talk about in the company of the coldly analytic.  Nonetheless when I figured it out the deliveries went better.

But I didn’t sugarcoat the problems that I had at my last delivery (see the post from April 2010, https://walkaboutdoc.wordpress.com/2010/02/24/my-cancer-removed-reflections-on-being-a-male-in-ob-a-frightening-delivery/.

We discussed beepers and the psychiatric community and why the dynamics roll the way they do.  And we talked about writing.

She might start blogging.

A Surgeon’s Funeral

December 8, 2014

He was a surgeon to know and admire
To snatch the fat from out of the fire
He came to the ill
With grace and with skill
A light when things were most dire.

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, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.
Medicine has always been a team sport.
When I first came into private practice from 5 years in the Indian Health Service, I had to get to know the specialists. In less than a year, I established a reputation as a sharp diagnostician. In retrospect, though, it seemed to me that very complex clinical situations presented themselves to me in such an obvious fashion that I could make an outstanding diagnosis and look like a hero.
For example, I diagnosed 8 women with ectopic pregnancy in 6 months. The principle has long stood that any woman of childbearing potential with abdominal pain has ectopic pregnancy until proven otherwise; I embraced that piece of wisdom and saved lives. But each one presented on a different gynecologist’s call night, so that in short order my consultants came to trust my judgment.
On one particular night, I called a surgeon and said (the patient’s identifying data may or may not be precise) “I got a 14-year-old white male with increasing abdominal pain times three days, originally vague and near the umbilicus (navel) now localized to the right lower quadrant, worse with jarring, accompanied by loss of appetite. No major medical problems in the past. He has decreased bowel sounds, a little guarding, tender at McBurney’s point, rebound, referred pain to the right lower quadrant, and positive heel, psoas and bunny hop signs. He did not enjoy his lunch. Blood and urine are normal. I think he has appendicitis, and I’d appreciate it if you’d see him.”
In those days the primary care doc scrubbed in with the surgeon as assistant. I watched in awe as he flowed through the surgery in less than 5 minutes; poetry in motion and economy of movement really don’t do justice to the beauty of how his hands worked. Before the advent of laparoscopic surgery, he could do an appendectomy with an incision less than an inch long.
The guy was slick.
We did a lot of those cases together, and as the critical first months in a new medical community passed, I built such trust with my consultants that I could say, “Hey, Don, you wanna go fishin?”
We worked well together.
As medicine progressed, we both aged. He retired a number of years ago.
He died last week, and I went to the funeral today.
I saw a lot of the docs I knew from those days; a urologist who had left town last century, a half-dozen Family Practice docs, three surgeons who had worked with Don back in the day, two pathologists, a radiologist; some retired and some still working.
The service had a light mood; Don had a full life and enjoyed tremendous respect.
I held the door for the widow after the internment. I hadn’t known her to speak of but she looked at me and stopped and addressed me by name. “Don thought the world of you,” she said, “He said you were one of the sharpest doctors in town. He admired you.”
I hadn’t known that. It meant a lot to me.
“I admired him,” I said.