Archive for October, 2015

End of the Summer of Urgent Care

October 25, 2015

I could do as much as I’d dare

Sometimes not a moment to spare

From the first to the last,

It sure went by fast,

The summer I did Urgent Care.

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

The vast majority of Family Practice involves delayed gratification or out-and-out frustration, the exceptional case, where the patient leaves better than when they walked in, comes as a treat.  When I owned my own private practice, I would have one or two a week.  Two would make a day, but a standard Urgent Care shift might include six.  Drain an abscess, stitch a laceration, remove a foreign body, clean out ear wax, splint a fracture, or take off a tick or any fraction thereof.

But I couldn’t give the anxious and depressed people my version of hit-and-run counselling.  Nor could I do much with the rather fascinating cases that required labs or sophisticated x-rays.  And if an x-ray showed a problem needing further imaging such as CT or MRI, I wouldn’t be part of the resolution.

I sent so many patients out by ambulance for chest pain that I can write about the aggregate without revealing any unique patient information, but I can say that people mainly concerned with chest pain shouldn’t come to Urgent Care.  I can say the same of the people who have the worst headache of their lives, severe abdominal pain, or anything problem related to pregnancy.  I won’t know what happened to those patients, nor the final diagnosis.

I saw very unusual x-rays and physical findings, but Urgent Care by its nature doesn’t involve follow-up, and I’ve resigned myself to not knowing.

When I took care of a person with a substance abuse problem, I had to make do with the briefest of interventions, but I suspect I did as much good, if not more, as I did in those cases where I had 45 minutes to spend.

I cared for 47 patients over the course of 12 hours my last day (this go round) in Urgent Care. I sent for the ambulance 3 times, I urged 4 more to the ER as soon as they could get there.  Out of 4 x-rays, 2 showed fractures.  For every patient for whom I prescribed antibiotics, I advised 4 that antibiotics would probably do more harm than good.  This late in the year I diagnosed poison ivy 4 times, with reactions much lighter than those I saw back in June.

I washed my hands or used alcohol based hand rub twice, minimum, for each of those patients, and I don’t anticipate the skin on my hands recovering for a week.

With that kind of patient flow I didn’t get a chance to talk to people about their lives.  I didn’t get to the fine points of social context leading to disease.  I missed quizzing people about the details of their occupations and hobbies, and learning about the wider world from the contact.

So I found the summer of Urgent Care gratifying but not satisfying.  Long, hot days have passed and the leaves are turning.  One morning I had to scrape frost from the windshield.  The action and immediate gratification might bring me back but for the time being I’ll work on something else.

Gravity and wound healing.

October 22, 2015

When it comes to a wound and pain,

Think of gravity to help and to drain

Leave out the drugs

Prop up with some rugs

And cut out Big Pharma’s gain.

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

Sunday went slowly till the last, a patient or two an hour.  I got time to eat lunch and supper without rushing.

I saw a lot of respiratory ailments today.  Most people get a runny nose, a low-grade fever, and after about 4 days a sore throat and a cough.  So far, the strep and influenza tests keep coming back normal.  I counsel patients about Tylenol, rest, and fluids; antibiotics would have a greater chance of harming than helping.  And, indeed, recently I saw a couple of bad reactions to antibiotics.

One of the non-respiratory patients, extremely sharp and quite elderly, came accompanied by an offspring.  The therapy recommended a couple of weeks previous had failed to resolve the problem  I observed that swelling in a limb puts the skin under tension and makes wound healing impossible.  Thus to fix an ulcer on a swollen ankle, one must first fix the swelling.  In the majority of cases gravity will drain the edema.  During my 23 years of private practice, I regularly hospitalized patients for non-healing diabetic foot ulcers.  I called in a podiatrist consultant, whose therapeutic mainstay consisted of keeping the patient’s feet elevated above the level of the heart.  It always worked.  So I told the patient to stack blankets and towels on the recliner to keep the foot higher than the heart by at least 12 inches and preferably 18.  Pillows don’t work, I explained, because they compress.  And if we can just keep the part involved elevated, chances are you won’t need other therapy.  And if you don’t keep it elevated, all the antibiotics in the world won’t help.

I needn’t have worried about unselling the drugs; the offspring currently studies naturopathy.  The patient related a family member’s story, full of drama and irony and reflecting poorly on my industry, as the background for a low enthusiasm for medication.  I couldn’t argue with the conclusion.  And my approach, using a low-cost, low-hazard, readily available commodity (gravity), met with great approval.

I had barely finished the documentation when the evening rush started with six patients checking in after 7:00PM.  I still managed to get my charting done by 8:17PM, and walked out into the darkness.

Bits and pieces from a couple of days in Urgent Care

October 16, 2015

I explained the news in a flash

About laws confusing and brash

With circumstance and pomp

In workman’s comp

We’re not allowed to take cash.

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I’ll leave out the tortuous background story of why I came to speak Spanish fluently, but I find myself in 21st Century USA with a talent highly valued in the medical profession.

While the United States recognizes an employer’s moral obligation to take care of workers’ on-the-job injuries, each state has a different system and the best of them have Byzantine and incomprehensible nuances.  I have little legal vocabulary in English, and my only Spanish legal vocabulary comes from reading the translation of John Grisham’s Runaway Jury.  English language explanations carry a high level of difficulty that goes to mind-boggling on the other side of a language barrier.  The front office called me up to translate; it got worse when I explained that acceptance of cash for this particular case would have broken the law.

I got a chance to talk to a patient from Uruguay.  The mention of the patient’s hometown brings back wonderful memories and we talked with relish about the high-quality cheese and yogurt that come from the government dairy monopoly.

Occasionally the nurses need me to explain urine drug testing in Spanish to prospective new hires.

But sometimes a day or two goes by without speaking Spanish, and I miss it.

I took care of a patient with a straight-forward ear problem.  After successful resolution I confessed that making people better before they leave keeps me in the game; it’s the doctor’s moment.  Maybe because I listen well, or maybe because my face encourages people to talk, or maybe because the patient was ready, at the end of the visit I listened to a story brimming with more irony than drama but plenty of both, and not reflecting well on my profession.  I explained that as a front-line doc, someone else always knows more than I do about, for example, escalating abdominal symptoms.  At home, I said, I know exactly which doctor I’d send you to.  And then I talked about the inherent problems of being a team player and knowing nothing about the local talent.

Towards the end of the day I attended  a child.  The medical problem soon taken care of, I reached into my pocket and brought out my yoyo, as I usually do at the end of a visit if children are present.  For the first time ever, the parent brought out the telephone video camera to bring back a visual for a sibling.

I attended an English teacher, and I mentioned my writing. We agreed on the difficulty of writing to both genders, and how males in the school system get left behind when it comes to literature. I assured the patient that without me, the inciting medical problem would resolve eventually, but reading West With The Night by Beryl Markham would make for a richer life. We would both like to see English teachers have more input into curriculum.  I talked about the importance of effective written communication when physicians have to send letters or emails to non-physicians..

Eternal Verities of the Human Condition

October 8, 2015

When patients come in by the mob

And I can feel my feet start to throb

Though the place is a zoo

I can tell you it’s true

I really do love my job.

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I walked into work full of energy this morning, to an Urgent Care site where I’d never worked before.

At home I generally see a patient or two a day when I’m not working, mostly informal visits.  Some people leave with concrete advice.  Sometimes I enforce an exercise prescription by going on a walk with the person.  Occasionally I’ll serve breakfast.  People most often get advice, rarely a prescription for a pharmaceutical.

Frequently a person goes to a specialist as already scheduled, with advice on how to use buzzwords, give an accurate history, or ask for lab tests.

This particular clinic has a history, and it made me appreciate the care put into other clinic’s floor plans.

Over the course of the day I saw people with broken bones, skin problems, and respiratory infections.  I brought into play recent information from the conference I attended in Denver, especially about when to use and when not to use antibiotics and narcotics.  Some people left disappointed, but no-one left without attention to their problem.

Starting slowly, I soon had a five-hour crush of patients.  At two in the afternoon things slowed down enough that I could attend to my raging hunger.  Bethany sat with me in the break room while I bolted fries and smoked brisket.

After lunch I caught up with my documentation.

A quick run through my email showed me that my planned next step had fallen through.  I have no work on schedule as of November 1.

Weight loss in 21st century America demands investigation.  People who delay treatment for trauma will generally suffer more problems than if they’d come in early.

I did most of my antibiotic prescribing in the late afternoon and evening.

I didn’t get to speak a word of Spanish.

I don’t do much surgery, but I got the chance to remove a patient’s problem and found the experience delightful.

During a slow hour I asked Bethany to bring food at six, when she showed up things had backed up badly.  But I took 4 minutes to inhale some hot sour soup and orange chicken.

Without permission, I can’t give identifying details about the last patient of the day, leaving the philosophical distillation in a jumble..  My business sees the exquisite drama and irony because of these inherent truths:  mortality tinges human love with an urgency, we all climb a ladder of development, our bodies age no matter how we try for a perfection we cannot attain, and we spring from, in Kahlil Gibran’s words, “life’s longing for itself.”

I walked out into the cool October night, full of wonder.

I Sent My Medical License Application to Canada.

October 7, 2015

A surveyor came to the door.

The design of the questions was poor

Doctors’ treatment gets worse

Regulation’s a curse!

And the EMR is a chore.

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

After wrestling with a recalcitrant, truculent printer, I put together a packet to go to PhysiciansApply, a Canadian agency that helps doctors put their credentials into one central place in the system, so that the various provincial licensing boards can access them.

They wanted: notarized copy of passport, a copy of my American Board of Family Practice certificate, a copy of my residency certificate, a copy of my medical school diploma, a copy of my Iowa medical license, and a Certification of Identity.  This last form required 2 passport pictures less than six months old and a Notary stamp.

I understand the need for these documents, especially, from the Canadian point of view, because I’m an International Medical Graduate.  I hope they go through a thorough verification process.

Luckily I live in a small town, where I can get passport pictures at a nearby drugstore and my next door neighbor has a notary credential.

I sent the packet via FedEx.  I have only sent things internationally once before, when I went through a similar procedure for New Zealand 5 years ago.  I had never considered the importance of declaring contents for the purpose of customs.

A survey taker came about two hours later to ask loaded questions about the Affordable Care Act, also known as Obamacare.  He carried an electronic device.  I sat on the glider on the front porch and leveled with him.  In my experience, every time the taxpayers squawk loud enough, the kleptocrats cut meat from the program rather than fat, so that the taxpayers complain louder, the program gets expanded, and the taxes go up.  I think our government spends too much and spends foolishly (and a lot of that has to do with health care).  But I think we should tax the wealthy more and not tax the poor at all.

I also told him about my experience in Denver, talking to doctors at the breaking point.  The Electronic Medical Records keep getting worse, paperwork requirements keep getting worse, reimbursements keep going down, and the ACA failed to bring in tort reform.  I talked about my fears that our medical capital, our primary care physicians, will start leaving the country.  Already, Canada offers better incomes and more protection from medical malpractice suits than the US.  New Zealand has a polite society, a great EMR and no medical malpractice at all (no tort law, for that matter), a lower income for doctors who have found a good work/life balance.  Australia doctors work hard, bill fee-for-service, and make more than American doctors.

And then I told him I had, that very day, sent my application to Canada for a medical license.

I didn’t tell him I had no intention of moving there.  I want to try the system out, and write about it, honestly.

Beware the commercial bias

October 4, 2015

Over lunch I listened to plugs

For some marginal toe-nail drugs

We don’t have any more

Of the big disease score.

We’ve got shots for most of those bugs

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

The first lecture I attended at the American Academy of Family Practice Family Medicine Experience (AAFP FMX) included a very nice lunch, and an unappetizing talk on toenail fungus, or onychomycosis.  I don’t mean that the slides depicting deformed toenails took away my appetite; rather, I found the commercial bias disgusting.  We have new agents that, according to the presenters, work better than the old agents, but at best they bring a 35% cure rate.

The next lecturer, playing by the book, revealed commercial connections to several Big Pharma companies.  The presentation that followed would have bored me to tears if it hadn’t put me to sleep.  The format consisted of study after study in excruciating detail, all research sponsored by drug companies.

But the next two talks had nothing in their full disclosure statements and featured evidence-based meta-analyses with rank ordered recommendations.  One presenter qualified as a gifted teacher and a passable stand-up comedian.  He made the analogy between musculo-skeletal injuries and crime scenes: identifying the victim comes easy, but identifying the culprit takes work and wisdom.  Thus applying ice to a painful knee matters less than finding the weak muscles and tight tendons that led to the problem in the first place.

I have come to terrible cynicism regarding the American pharmaceutical industry.  They make wonderful drugs for the most venal of motives.

In a discussion over lunch, I talked to a doc who has been working in Africa for the last couple of decades.  He helped put the small pox genie back in the bottle, and is very cynical about the possibility of ending polio.  He retired into private practice but prior to a a year ago, he worked for an NGO.  Around the table we talked about how vaccinations have made the biggest changes in our business.  Most docs finishing residency now have never seen measles, mumps, polio, epiglottitis, or periorbital cellulitis.  Polio was rare when I did my training; if my sister hadn’t had it in 1953 I would never had seen it.

A Doctors’ Trade Show

October 2, 2015

I went to the doctors’ trade show

And met some folks that I know

And made some new friends

Who have the means to the ends

And, all in, all, seem like a pro

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

After a three hour lecture in the morning, I went to the Exhibition Hall, a trade show for an audience of 4,000 doctors.

All the big drug companies have booths here, where “booth” can mean a display with 4 figure square footage, 6 figure inventory, double digit staff, high-tech lighting, and luxurious carpet.  The device manufacturers send representatives, too, along with recruiters, hospital systems, healthy and unhealthy food manufacturers, shoe makers, massagers, electronic EMR companies, publishers, lab companies, financial managers, 14 government agencies, imaging corporations, instrument manufacturers, market research concerns, office equipment vendors, practice management consultants, and almost everyone who wants to hire a Family Practitioner.

I could not find the company that made the recalcitrant EMR which led to my departure from Community Health back home, probably for the best.  That company’s exit from the field would not surprise nor disappoint me.

I visited the booth of the Urgent Care company I’ve worked at this summer, and bubbled over at how much I’ve enjoyed the experience.  They plan to open a center 4 hour’s drive from my home, and they offered me a more permanent spot.  All they want is a commitment to 10 shifts a month.

I also visited the representatives of the company that place me there.

But first I had a most productive talk with the Canadians, and I learned a good deal.  They explained some salient points about the credentialing process which the website does not make clear, especially regarding notarization of credential copies.  I established a relationship with a recruiter for a government agency, and expressed my willingness to work rural establishments.  The first step, a provisional license, will require a 3 month commitment, and, after that, I can do locum tenens work as I choose.  The country’s socialized medical system regards the doctors as independent contractors, and most work fee-for-service.  Medical malpractice exists, but a doctor has to really screw up to get hauled into court, and professional liability insurance, provided by a government agency, has remained affordable.  I walked away stunned.

Limited Options: in the wake of Obamacare

October 1, 2015

What are they trying to prove?

With this Obamacare groove?

We have limited choice

And limited voice

If worst comes to worst, we can move.

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 (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

After lunch I sat in on a round table with a group trying to get out the message on a single payer system.  Our insurance companies currently take between 20% and 25% of our health care dollar and return nothing of value (physicians get 9%).  For every doctor we have two people employed by the insurance industry.  Doing away with the insurance companies would not cure all, but it could go a long way.  A doctor at the table made the comment that we already have a model for a single payer system in this country, TriCare, which gives medical care to Department of Defense, and the Veteran’s Administration.

Yet American doctors love to hate the single-payer Canadian system.

We all voiced frustrations with currently available Electronic Medical Record (EMR) systems.  Updates uniformly brought progressive loss of functionality.  The VA’s system, in use for decades with no updates, continues to function well.

I talked about my experience in New Zealand, a polite society with a very good medical system and a single, nation-wide EMR.  Socialized medicine, but ruled by reason.

Doctors in the US have seen their productivity fall by 25% since Obamacare; we spend increasing amounts of time keyboarding and jumping through regulatory hoops.  We devote more time to documenting the visit than we spend with the patient.  We have few options:  live with the way things are, move, find another line of work, or go to Direct Patient Care (DPC).

DPC means that the patient pays the doctor directly.  In concierge practices, a fixed yearly amount brings the doctor’s promise to limit the panel of patients to a fixed number and provide quick access with unlimited long appointments.

Other DPC docs perform primary care services, take cash only, and give the patient a receipt.  The patient can, if they choose, submit the bill to the insurance company.  Dealing with insurance requires one employee per doctor; elimination of insurance means lower overhead.  More than that, senseless time-sucking regulations can be ignored.

I hear doctors speak seriously about moving.  They would take a cut in pay to spend more time with patients and deal with a more reasonable system, even a single-payer system.

I want to work in Canada to experience it first-hand.  And when I come back, I might work locums for the Department of Defense and/or for the VA.