Archive for August, 2015

A Canada license takes time.

August 28, 2015

I wait, and I don’t get a call

About Canada and the upcoming fall

I’m a little bit vexed

What shall I do next?

I’m about at the end of my stall.

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 travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

Work proceeds on my Canadian license.

Just as each US state has its own medical licensure board, so does each Canadian province.  Just as once licensed in, say, Wyoming, getting licensure in Colorado becomes much easier, similarly a license in British Columbia will make other Canadian licenses less complicated.

My New Zealand license worked for the whole country.  I never even learned all the districts.

But the first Canadian license takes a lot of time.   I started in April.

In New Zealand, compensation came as a package, with no room for negotiation.  The agency got all its funding from the state, and took nothing from either the doc or the client.

My Canadian recruiter receives a finder’s fee from the client, but the doc negotiates directly for compensation, transportation, and housing.

In the US, the recruiter negotiates things like rate, which always includes transportation, car rental, housing, and professional liability insurance.  Those negotiations represent value and labor, and the recruiter gets a chunk of the total package.

Thus less of the total pie in Canada goes to the recruiter and more to the doctor.

The process has gone slowly.  So slowly that I have started to question the viability of an October 6 start date.  Part of the problem stemmed from the 2 weeks’ vacation taken by a key player in the licensing process, another part came from unclear expectations for documentation.

Bethany and I have started talking about where we want to go if Canada falls through, and we came up with Wyoming, Navajoland, Alaska, and Puerto Rico.

We’d like to go back to Wyoming, where we originally met, and, after our experience in Alaska, the idea of the winter doesn’t scare us.

When we arrived in Navajoland I had just finished residency, our first child hadn’t had her first birthday, and we grew together as a couple there.  The Indians taught us a lot about hospitality, and I learned to hunt there.  We’re both curious to see what has happened to the culture in the last 30 years.  And certainly the culture has changed.

I’ve now made seven trips to Alaska.  It’s a very, very big place, and I’ve only scratched the surface.  I’ve not experienced the interior or the Mat-Su valley.

Bethany suggested Puerto Rico because living there would force her to learn Spanish.

And, all in all, we’d rather have a good spot in Wyoming than a bad spot in Puerto Rico.

But the American Academy of Family Practice’s Annual Scientific Assembly starts in a few weeks in Denver, and I know that I’ll be able to talk to dozens of recruiters.

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I estimate my exercise output and my caloric intake badly

August 27, 2015

How much was it I ate?
I don’t know, but I can estimate
I know that I guessed
And it wasn’t the best
But there’s no denying the weight.

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 travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

Most Americans struggle with their weight because human beings are lousy estimators. We badly estimate how much exercise we got and we badly estimate how many calories we have in front of us, and our waist lines slowly expand.
Working Urgent Care, I can eat a decent breakfast before work. I don’t take a formal lunch or dinner break. Sometimes I get lunch, and sometimes I don’t. I will, as instructed, eat enough to keep making good decisions, which generally means stepping into the break room in the midafternoon and wolfing down some provided snacks (I prefer Goldfish and peanuts).I try not to eat supper, because, like the majority of Americans, I struggle with my weight. Mostly, I fail, and I end up eating something when I get back to the hotel. I try to keep it light. I don’t always succeed.
When I used to work 12 and 14 hour days in private practice, I could exercise after work because my day started at 5:15AM, but the 8:00 to 8:00 schedule precludes exercise late or early without significant loss of sleep.
Wednesday, when my work week finished, I ate supper, and next morning ate an enormous breakfast. The trip home met with delays and cancellations, and the airline provided us with meal vouchers. Bethany prefers to travel hungry, but with 6 extra hours at Chicago O’Hare, I used all $24 to buy a mushroom torta, chips, and guacamole. I ate with guilt, aware I’d missed a lot of gym sessions and I hadn’t missed enough meals. Which didn’t keep me from snacking on chocolate almonds while the next plane boarded late.
One of our friends drove down from Sioux City to Omaha to pick us up. We drove back in the dark, arriving home to face two weeks of mail, neatly laid out on our kitchen table.
The next morning I gritted my teeth before I got onto the scale.
To my surprise, I’d lost 4 pounds in the two weeks we’d been away.
I didn’t snack as much as I thought. But I also have to figure that I got more exercise in the course of a day’s work than I’d realized. A pedometer would give solid numbers.
If you estimate well, you can generally find work, well, as an estimator. My track record on estimation, poor at best, keeps me out of that line of work. Which means I’m a lousy estimator.
Like most human beings.

Trade offs in Urgent Care

August 11, 2015

I enjoy my Urgent Care job
The patients come by the mob
But sometimes it’s our fate
We’re not done, but it’s late,
The rush just makes the staff sob.

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 travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I enjoy my current gig for an Urgent Care facility in suburban Pennsylvania.

My nominal work hours run from 8:00AM to 8:00PM. I go late on average one night out of three. Patients generally come in with problems of short duration and intense acuity. Most have a primary care provider who can’t see them in less than 3 days. Because management has developed a patient-centered approach, I do little redundant clerical work and thus I can spend a lot more time concentrating on patient care.

So far this week slow patient flow in the morning has given way to a brisk pace in the afternoon. Staff morale stays high, the big gripe comes against the rush of patients that starts after 7:00PM (about half the time). So tension builds on quiet nights as the clock ticks out the last half hour.

Poison ivy made up half the business back in June, but is now decreasing in frequency and severity. I have sewn up a lot of finger and hand lacerations. Two or three times a day we have the joy of curing the patient before they leave, mostly by taking out ear wax; but we also drain an average of one abscess a day. A majority of the x-rays I order show fractures.

People around here like to vacation at the beach, mostly New Jersey,Virginia and the Carolinas. We get a significant number of patients with swimmer’s ear and urinary tract infections related to the travel and swimming. And also the worried well who don’t want to be sick while on vacation.

August brings in the sports physical crowd. Basically healthy, the rare surprise disqualifications justify the activity.

Then, sometimes, with such a high patient volume (I consider 30 in a 12-hour shift light), serious illness demands an ambulance or an injection. Twice so far today I’ve advised patients to go directly to ER.

Earlier this week I helped wheel a patient into her waiting vehicle. I enjoyed breathing the warm summer air and smelling growing vegetation and seeing the summer thunderheads building in the north.

Occasionally a physical finding I’ve never before seen heralds a puzzle, and I refer to a specialist.

We refer all broken bones to orthopedists.

Urgent Care has its share of joys but so much of the fun comes from the fast pace and the easy-to-solve problems that the awe and mystery of unraveling complex disease one lab result at a time gets lost. An upscale, insured population obviates the opportunity to serve the under-served. And I miss speaking Spanish.

Life always involves tradeoffs.

9% Grade: New Bethlehem to Kittaning

August 9, 2015

Many the story I’ve told,
About the horrible hills I once rode,
I know where I’ve been,
To ride them again
Would ignore my life’s lesson code.

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 travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I finished my first undergraduate career in 1972 with no plans for the future aside from bicycling back from New Haven, Connecticut home to Denver, Colorado. I went with Al, a roommate for 2 years.

I sent my winter clothing, bedding, and books parcel post. I looked at everything else I owned and divided into two piles: one to take with me and one to throw away.

The trip changed my life. Four years later I sat in a small room in East Lansing, Michigan, at my fifth and last medical school interview. The first four had gone poorly and I saw my last opportunity at my life’s goal hanging in the balance. In desperation, I spoke from my heart on what I learned that summer about the rhythms of the earth from lessons in bike repair, camping, weather, traffic, and minimalism. That interview ended up a fantastic success, and I got a place at Michigan State.

I started the trip with 32 pounds of gear and finished trip with 26; the bicycle weighed 34 pounds and did not change materially. Bicycles became embedded in my life that summer; I bought Bethany a tandem instead of an engagement ring.

In the summer of 1975 I rode from Denver to San Diego in 11 days, and over the years I commuted so many miles that I could look at a derraileur and say, from experience, that it would only last for about 5,000 miles.

The worst hills I could remember came that first long trip, in the 19 mile stretch from New Bethlehem to Kittaning, on Route 28 coming into Pittsburgh from the north. It took us three hours, and we didn’t know if we could make it the rest of the way to town (we did).

But sometimes a forty-year lens magnifies misery. I wondered if that stretch really had that many steep hills; on my day off I decided to drive it in the rental car.

Coming north from Pittsburgh, I recounted to Bethany the horrors of that trip, and wondered aloud if it really had been that bad.

Yes, it had been, long steep grades separated by no more than 50 yards of flat. One sign, coming into New Bethlehem, that we wouldn’t have seen from a bicycle headed south, said “9% GRADE TRUCKS USE LOW GEAR.”

Nine percent?

NINE PERCENT??!! A railroad can’t climb anything steeper than 6%; neither Casper Mountain in Wyoming nor Mount Taylor in New Mexico came close. And this thing went on for a couple of miles, and dropped almost as badly on the other side.

With such focus on steepness, I failed to remember the narrow and sometimes non-existent shoulder.

I thought back to other superlatively negative experiences: high school, the worst night on call (38 hours with one 45 minutes break), the heaviest clinic day (63 patients in 6 1/2 hours), the worst Electronic Medical Record (Centricity).

I accept my memories as accurate, I don’t have to do those again.

Iowa house calls, back to Pennsylvania

August 7, 2015

For a house call I went to a store
Then expected one or two more
To come to my house
So I said to my spouse,
They’ll come in through the front door.

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 travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

While home in Iowa last week I made a couple of house calls.

One patient owns a business I frequent, and had called me when we were both on the way back to Iowa. Our professional relationship dates back well into the last century. We have watched each other progress professionally and socially. He gave me the go ahead to write the entire visit in this venue as a record, but, for the same reason I conducted the interview on the deserted freight dock and the exam in the store’s quietest corner, I didn’t. At the end, he personally helped me with my selections and would not accept money for the transaction; nor would I accept payment from him.

Another friend has had a problem building for months; we agreed on the next step: the specialist.

The garden has come in, and Bethany and I snacked on the first of the tomatoes, cucumbers, and green chiles; We invited company for supper on Friday. For a side dish, I cut sweet corn from the cob, added red onion, roasted green chiles, lime juice, and olive oil.

I took call for my Community Health Center the weekend. One patient discharged from peds on Saturday and one admitted on Sunday,far cry from a census demanding two docs to round both mornings, with one up all night to take admits and calls.

Tuesday found us back in Pennsylvania, at an Urgent Care, working 12 hour days, but this time we can walk from the hotel to the clinic. I like the medical record system. I can whiz through documentation for respiratory problems, but skin and musculo-skeletal problems need more narrative because no two are the same. A disproportionate number of patients come in with poison ivy.

Urgent Care, by definition, doesn’t include ailments that need follow-up or CT scans. I sent a number of patients each with suspected heart attacks, blood clots, or kidney stones to the local ER. People with bipolar disease tend to have very real, severe physical problems. I can treat those injuries, but getting at the root cause falls outside my scope of practice.

To those patients who come in, for example, with weight loss (now into the double digits working for this client) I say, “This is not normal, but there is a limit to what can be known an hour, and there is a limit to the lab we can run in Urgent Care. You need a primary care provider, and here is a list of labs that he or she might run.”

Nor can I effectively treat rheumatologic problems, but rheumatologic patients come to see me nonetheless. From time to time I run into people on Enbrel, and then we generally have a happy support group meeting. We talk about how the drug changed our lives; how, coming out of the pain we could engage emotionally with our families; and about how, outside the pain relief, we just feel better; (I feel better now than I did at age 18).

If I talk to a back pain patient on opiates, I tell them how the medication inhibits their own ability to make endorphins and perceive endorphins. Some express shock and amazement, and some just want me to prescribe the Norco, because “it’s the only thing that works.”