Archive for July, 2015

The script our parents give us

July 22, 2015

To the problems I can relate
My family was in a sad state
Let’s call a halt
To blame parents’ faults
We’re obliged to master our fate.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

After a week off, I addressed the drama and irony behind the first patient’s very real physical problem from the perspective of my own experience. My mother had borderline personality disorder, my father had narcissistic personality disorder; no medication exists for either of those two problems. I observed that we don’t get to write the script that our parents hand us, but we have the obligation to edit it, and that obligation gives us freedom. Stressed people get sick, and sick people get stressed. Some of the stress that life brings us we cannot avoid and we just have to deal with it, but some of our stress we make for ourselves.
I saw a lot of people sick in the aftermath of a death in the family. For some I mentioned my brother-in-law’s untimely drowning and we had a mini support group. With others I talked about my 11 culture proven strep throats in the 10 months after my mother’s death.
Early in the day I recounted two stories to the PA I worked with. The first had to do with a different clinic in a different century, during the days of paper charts, when I caught myself over emphasizing the importance of thyroid testing to a med student. “Think thyroid!” I pontificated. “Depression? Think thyroid. Weight gain? Think thyroid. Weight loss? Think thyroid. Diabetes, hypertension, or cholesterol? Think thyroid.” We walked up to the next exam room, and I pulled down the chart so we could read the chief complaint on the routing slip.
“C’mon,” she said, “Sore throat? Think thyroid?”
And with a trifle more certainty than my experience justified, I said, “Think thyroid!” We walked into the room, I said to the patient, “Take one finger and point to where you hurt the worst.” She pointed to her thyroid, and turned out to have Hashimoto’s thyroiditis, with an anti-TPO about 100 times the upper limit of normal. I hope the med student recognized the luck that played into that impressive bit of diagnosis, but still went on to test the thyroid for the least justification.
The second story had to do with a patient in another clinic in another state, who might have come in for one thing but routine exam picked up an irregular heartbeat and EKG showed atrial fibrillation.
All in all, the day went well. The PA stayed till 2:00PM. I ordered delivery Chinese, and inhaled forkfuls of fried rice between patients.
The last patient of the day teaches high school history. We had a marvelous but all too brief conversation about that subject. While some might complain that current history curriculum includes an excess of politically correct material, I remember clearly the Cold War propaganda from my own high school days; we students recognized that material as a pack of lies. Which inspired me to study history on my own, and to find out the real story.

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Horse rescue, poison ivy, and Irkutsk

July 22, 2015

If your work brings you down in a ditch
Poison ivy can bring a bad itch
For the leaves that are three
You should just leave them be
And Zanfel fills in the niche

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

From time to time I ask patients to include some of the fascinating details of their lives in my blog. I leave out diagnosis, age, and gender unless relevant to the story, whether the patient gives permission or not.
I had a fascinating conversation that started with my use of a few well-pronounced words in Russian. The patient peered at my name tag, and observed that my last name didn’t look Russian. Perhaps not, I replied, but we had that name for a thousand years in Lithuania; when the Mongol era globalized trade, the king of Lithuania imported Scots traders to try to build a middle class. In short order, I revealed my grandfather’s fleeing Tsarist Russia east through Irkutsk, the patient’s birthplace; and in turn learned of the patient’s Yupik heritage. So I could tell of the man I met in Nome whose family had fled from Stalinist Russia to Alaska in an umiak. At the end, I said “thank you” in both Russian and Inupiaq.
Another patient works on a large animal rescue team. During a lull I quizzed the patient about work, and listened, fascinated. The medical problem was routine, the horse rescue anything but.
I see a lot of poison ivy problems here, and I can always find a story in how it happened. Usually it comes in the context of social stress, frequently marital discord. But sometimes it happens in the course of work. On more than one occasion I said, “If you’re the boss and your crew works outside, it’s worthwhile for you to get a case of Zanfel and hand it out and tell them to cleanse with it if they start to itch. And you can probably get a case of the stuff for less than the price of two doctor visits.”
I’ve had to learn a lot about poison ivy. Non prescription Zanfel does a good job of binding the resin away from the skin (hence my recommendation). Systemic steroid use less than two weeks usually results in rebound itch and a phone call, and is not justified if less than 10% of the skin is involved. Hydroxyzine is a powerful anti-itch medication that doubles as a sleeping pill. And most people can handle the itch during the day, but they come for relief because they can’t sleep.

Thinking thyroid, learning history

July 21, 2015

Here’s something that we should note
For a diagnosis I’ll throw in my vote
When it comes to life’s stress
The immune system’s a mess
Is it really just a sore throat?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral and a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.
After a week off, I addressed the drama and irony behind the first patient’s very real physical problem from the perspective of my own experience. My mother had borderline personality disorder, my father had narcissistic personality disorder; no medication exists for either of those two problems. I observed that we don’t get to write the script that our parents hand us, but we have the obligation to edit it, and that obligation gives us freedom. Stressed people get sick, and sick people get stressed. Some of the stress that life brings us we cannot avoid and we just have to deal with it, but some of our stress we make for ourselves.
I saw a lot of people sick in the aftermath of a death in the family. For some I mentioned my brother-in-law’s untimely drowning and we had a mini support group. With others I talked about my 11 culture proven strep throats in the 10 months after my mother’s death.
Early in the day I recounted two stories to the PA I worked with. The first had to do with a different clinic in a different century, during the days of paper charts, when I caught myself over-emphasizing the importance of thyroid testing to a med student. “Think thyroid!” I pontificated. “Depression? Think thyroid. Weight gain? Think thyroid. Weight loss? Think thyroid. Diabetes, hypertension, or cholesterol? Think thyroid.” We walked up to the next exam room, and I pulled down the chart so we could read the chief complaint on the routing slip.
“C’mon,” she said, “Sore throat? Think thyroid?”
And with a trifle more certainty than my experience justified, I said, “Think thyroid!” We walked into the room, I said to the patient, “Take one finger and point to where you hurt the worst.” She pointed to her thyroid, and turned out to have Hashimoto’s thyroiditis, with an anti-TPO about 100 times the upper limit of normal. I hope the med student recognized how much luck played into that impressive bit of diagnosis, but still went on to test the thyroid for the least justification.
The second story had to do with a patient in another clinic in another state, who might have come in for one thing but routine exam picked up an irregular heartbeat and EKG showed atrial fibrillation.
All in all, the day went well. The PA stayed till 2:00PM. I ordered delivery Chinese, and inhaled forkfuls of fried rice between patients.
The last patient of the day teaches high school history. We had a marvelous but all too brief conversation about that subject. While some might complain that current history curriculum includes an excess of politically correct material, I remember clearly the Cold War propaganda from my own high school days; we students recognized that material as a pack of lies. Which inspired me to study history on my own, and to find out the truth.

Broken computer: condensing a week’s adventures into 500 words.

July 13, 2015

No way to write for a week

Of the wisdom and truth that I seek

The inevitable token

Of the computer that’s broken

Is not for the heart of the meek.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

I sat in a lovely Pennsylvania hotel room tapping on my tablet.  With the July 5 post, including limerick, ready to go, I started in on the post for July 6.

I wrote the July 4 post the night before and published it that morning, after a good workout on the elliptical.  And publishing more than one post a day seems to me excessive.  When I can write ahead, I do.  Because sometimes the work goes late and I’m too tired at the end of the day to post.

I had gotten halfway through the limerick for July 6 when my tablet screen flickered once and went black.  Twenty minutes later, past denial, anger, and bargaining, I accepted that the lightweight computer had ceased functioning and I couldn’t revive it.  Nor could I write about the immediacy of my days; I would have to wait to return home to condense a week of adventures into 500 words.

I met really interesting people and I had much to write about.  I quieted frightened febrile children.  I prescribed a narcotic pain medication on the basis of a breathtakingly abnormal x-ray.  Under tight time pressures, I cut my motivational interview to the bone and got astonishing results, better than I ever did when I could give the patient an hour.  With not a spare second for judgementalism, smokers and drinkers decided to quit in front of my eyes.

I received no permission to write details about the psychiatric emergencies that I saw, but I can discuss the distilled lessons on the human condition that came from those cases.  Never put the keys to your happiness in someone else’s pocket.   Irrational behavior cannot elicit an appropriate response.   Families of psychotic patients suffer; the one who suffers most from physical manifestations of severe psychiatric disease most loves the person who loses contact with reality.

I took care of a lot of people before and after vacations.  The local patient population likes to go to the Atlantic seashore from New Jersey to the Carolinas.

Power went off briefly at the end of a clinic day, but not long enough to impact clinic function.

I had to give bad news over the phone several times, no patient expressed surprise.

I took time to grieve with those people sickened in the context of death of a loved one.  I brought comfort to them pointing out the force of human love derives from the fact of our mortality, and would be impossible if we lived forever.  I didn’t always footnote the source of that idea (a passage found in a prayer-book in the 80’s) and let it stand on the force of its obvious truth.

At the end of a heavy work week I turned down the prospect of time-and-a-half for another day’s work because of fatigue.  I visited my two married daughters and their husbands for three days.  I had lunch with a childhood friend.  I took away wisdom and learning with quiet joy, and flew back to Iowa.

Work on the glorious 4th

July 9, 2015

At one time I really liked running
The effect can be rather stunning
But a fracture from stress
Can make an ankle a mess
And test out all of one’s cunning.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m back in Pennsylvania.
Any patient information has been included with permission.

I started running in high school. My then undiagnosed hypermobility syndrome, combined with inadequate shoes, a penchant for running on pavement, my obsessive tendencies, a teenager’s natural urge to test limits and my sheer stubbornness resulted in stress fractures of my lateral malleoli, the outside ankle bones. I gave up running after my first (and last) marathon in 1981, and in ensuing years I have diagnosed stress fractures in fewer than half a dozen patients.
Thus my first patient on July 4 and I had a runner-to-runner conversation about stress fractures, the meaning of running, and what to do when you can’t run.
The pace of the holiday picked up after that, with 5 or 6 patients per hour. I got further and further behind on my dictations. I plowed ahead, happy to be back at work after two weeks absence.
The holiday did not bring an appreciable change in the case mix or demographics: lots of poison ivy and respiratory infections; about 40% of the patients under the age of 18. Nor did I see a single fireworks-related problem. But I saw more out-of-towners and people just back from vacation.
While I sewed up a laceration, I had an excellent discussion about knives and cooking with the patient. I got to recount the part of my New Zealand adventure involving sharpening knives to a razor edge on the back of a china plate.
About 1130AM I started calling to find out what Asian restaurants would deliver on the holiday. Too hungry for my own good, I splurged on sushi, but didn’t get a chance to get to the break room till 2:00PM, when the PA arrived. I bolted soup and seaweed salad and sushi, and, as the pace slowed down, I started catching up on my documentation, having fallen 14 behind.
I cleared the backlog. I joined the conversation. One of the nurses made a Dunkin Donuts run (I didn’t participate, but I finished off my sushi). With patients trickling in at 1 or 2 per hour, a quiet tension set in, waiting for the 759 PM deluge that never materialized. I left, hungry and tired, at 803 PM and drove right to the hotel.
I ordered a burger in the hotel restaurant at 820PM. The waiter visited me 5 times in the ensuing hour, while I read Teddy Roosevelt on my smartphone. The chef had variously just gotten back from break, gotten swamped, or gotten the order wrong. I found trying to stay awake harder than enduring the hunger. I started munching my sandwich, too exhausted to taste, at 920PM.

Trade-offs

July 3, 2015

I like to care for the sick

For me it just does the trick

But after reflection

I miss the connection

If the pace of my work goes too quick.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, and I just finished assignments in rural Iowa and suburban Pennsylvania. After detours for my brother-in-laws funeral and a bicycle tour of northern Michigan, we’re back in Sioux City.

I got a new computer.  I paid for the set up at the big box store.

When I returned to the store to pick it up, the young man helping me asked insightful questions about my career.  I didn’t recognize him.  He, however, recognized me.  I was his doctor, and, when he grew up, we used to see each other at the gym.

I delivered him and cared for him through his adolescence.  He has grown into a knowledgeable professional.  (He gave me permission to write more than I have.)

I don’t like talking about patients’ lives in public, and I enjoy talking about myself (frequently more than people want to listen), so I kept my end of the conversation about me.  I talked a lot about Alaska, and the freedom that locum tenens work gives.

Still the conversation brought me to reflection.  The 23 years I worked in private practice brought me intense professional satisfaction, but more than that it brought me to a perspective on the human condition that could only happen by intense involvement in people’s personal lives while staying in one place for more than a generation.

But inevitably, I had to talk about my 84 hour weeks, and a pace of work and life nowhere near sustainable.  I didn’t mention the 70% overhead that made slowing down impossible.

I also talked about what a great time I’m having on my current gig.  The Urgent Care outfit I work for has the problem Figured Out.  The top management, clinicians all, keeps the corporate vision of putting the patient first.  A person can walk into one of the clinics without an appointment, be seen in a prompt fashion, and be out in less than 45 minutes (the stated corporate goal).

I find the work very gratifying: single problem visits, almost all curable, resulting in easy documentation.  The patients tend to the younger age range, and I get to take care of an unusual number of older children and adolescents.

In the beginning, I felt a little uncomfortable taking away what I regard as the easy stuff from primary care providers.  But I heard over and over from my patients that their docs couldn’t get them in for 3 days to three weeks, or even told them to go to an Urgent Care.

Trade-offs fill the human condition.  I don’t particularly enjoy chronic care of medical problems which have treatments but not cures: diabetes, high blood pressure, high cholesterol.  But if I didn’t attend those problems I wouldn’t have the perspective for the grand spectacle of family development.  I like the travel and adventure of locum tenens, but I like running into people I know all over town (like in a big box store).

I would like to think I could find an optimum or a sweet spot.  More likely I’ll have to settle for one or the other, or even an oscillation from time to time.

Another road trip end: cherry picking vs. apricot picking.

July 1, 2015

Going home we just took our time

And the lunch tasted just fine.

We’re out to pick cherry,

It’s hard work, yes, very

But the jam we make tastes just sublime. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, and I just finished assignments in rural Iowa and suburban Pennsylvania. After detours for my brother-in-laws funeral and a bicycle tour of northern Michigan, we’re back in Sioux City.

We decided to take our time getting back to Iowa from Michigan, and to follow US 20.  But in Indiana, east of Chicago, we found speed limits 45 MPH and under, city center stop lights, right angle turns, and crumbling infrastructure.  We skirted Chicago on the Interstate on a weekend morning and rejoined US 20 .

We enjoyed the more leisurely pace of the traffic.  We stopped in Grundy Center to have a look around the town; we lunched at the Chinese restaurant.

Flat farm ground gave way to rolling hills as we approached our home in western Iowa.

All along the way we commented on the roads and whether or not we’d want to ride a particular stretch on a bicycle, dwelling on the factors of traffic density, steepness of grade, quality and width of shoulder, and smoothness of road.

When we arrived home I checked my cherry trees.

The plants in northern Michigan haven’t come nearly as far as the plants in Iowa.  We left corn less than 2 feet tall, green cherries, and blooming lilacs; we came home to corn 5 feet tall, fully ripened cherries, and lilacs weeks past flowering.

The next day we started picking cherries.

“Cherry picking” has entered the medical lexicon, and refers to the practice of selecting the easy, lucrative patients while leaving the more difficult and frequently uninsured patients to someone else.  You can find the term in both the clinical and financial realms.  It carries the connotation of laziness.

Real cherry picking, in contrast, involves a lot of work.  You have to haul the ladders or stand in the bed of a pickup.  You work over your head.  You hold a branch with one hand and pick with the other.  You stretch.  Every time you move a ladder you have to re-level.

Once picked, cherries need processing.  Even a hand-cranked cherry pitter takes work to separate the flesh from the pits.

In contrast, consider the apricots we picked last year.  You can stand on the ground and use a pole picker.  The action required for one apricot, about the same for one cherry, brings 5 times the weight of fruit.  Removing larger pits from larger fruits takes less time.

We love the jam we get from both, but pies we only make from cherries.

But nobody talks about apricot picking in a medical context.