Archive for November, 2015

Spotting the TSA agent with abdominal pain

November 30, 2015

Whatever the time or the space

The day of the week or the place

It won’t come as a shock

I’m always a doc,

And I could read the pain or her face.

 

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. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and working Urgent Care in suburban Pennsylvania.  Right now I’m in Virginia for the holiday.  Any patient information has been included with permission.

 

I travel with an expensive medication for my ankylosing spondylitis.   Every 5 days I take a shot, and I have to keep the stuff refrigerated.  I put a month’s supply into the smallest cooler in the house along with a gel cold pack, fully prepared to submit to TSA inspection.

With TSA Precheck, I didn’t have to take off my boots or show my computer at the airport in Omaha.  I stood in line waiting for my carry on to finish in x-ray, and I watched the TSA personnel.

The youngest member of the staff sat by the x-ray monitor, and stopped the belt when my backpack came through.  He summoned an older woman, either his supervisor or his trainer.  They conferred while I watched.  My medical training never stops, it’s who I am, and I saw pain on the face of the lightly built, blonde woman.  She might have hidden it from her coworkers, but not from me.  After a moment, I could see that her left hand spent more time hovering over her lower abdomen than anywhere else.  I couldn’t make a diagnosis without a good history and a physical exam, but I could see her abdomen swelled more than normal for a person of her build.  What could this be?  I asked myself, What’s the differential?

The two TSA officials conferred, they went back and forth.  After a minute, my backpack came down the belt, I picked it up and I walked on.

But I knew what had happened.  Pain lowered the standards of the TSA security official.  She had guessed, accurately, that I posed no threat.  But we already knew the TSA hassles constitute more placebo than real security.

***

I like to show off my talent for sharpening knives.  On arrival to Virginia, I volunteered to carve the turkey and immediately brought a shaving edge to the blade I would use.

Later that evening, one of the family members, chopping onions with that chef’s knife, cut the end of his ring finger, and the cut bled vigorously.

I have no license in this state, but, heck, anyone can apply first aid.  And I learned plenty of basics this summer working Urgent Care; I can’t remember a shift when I didn’t see at least one fingertip injury.  Mostly on the non-dominant hand (because the dominant hand holds the blade), and happened usually in a time of crisis or stress.  Dominant hand lacerations happened almost always on the job.

So we sat together, I applied local pressure, squeezing the area vigorously for 5 minutes.   The bleeding stopped, and I applied Superglue.

 

Cultural Sensitivity and Bogus Credential

November 29, 2015

Respect is my firm conviction.
but not for gross dereliction
The test, I suppose,
From a course that I chose
With scenarios that were pure fiction.

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 working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission

I woke this morning and started working on my Cultural Competence Module for my American Board of Family Medicine recertification. The ABFM didn’t write the module; the Department of Health and Human Services did. They used slick computer graphics. They could have gotten better writers.

The fictional patient that started the day, a 55-year-old Ethiopian with a heart attack, had switched doctors.  He felt he could talk to the African American physician more easily than the Chicana because they share racial background.  As the video developed, he wanted the new doc to come to a community meeting to lecture on good health habits.

Another scenario featured a distraught Spanish-only speaker with emotional problems getting worked in without an appointment.  She had overdosed her 14-year-old son on his prescribed amitriptyline (over sertraline due to cost) because the English word once means 11 in Spanish.  But the situation resolved in 4 minutes.

Yet another centered on a 74-year-old Vietnamese speaker with no English and loss of appetite, whom the doctor suspects has cancer of the cervix. Her 9-year-old granddaughter served as interpreter, ineffectively.

I firmly believe in cultural sensitivity starting with speaking to the patient in their own language, continuing to cultural respect, and not being judgmental.

The people who write the scenarios don’t know much medicine and they don’t know much sociology.

I worked with Ethiopians; the country has more than 80 ethnicities, languages, and religions, with overlap.  Christians and Moslems who speak the same language may or may not get along.  Ethiopians community meetings might exist, but, if they do, they happen rarely.  And I never met an Ethiopian who identified with African Americans, though some of the Moslems among them identified with me because of my beard.

Highly emotional people demanding to be seen without an appointment never finish in less than 45 minutes.  A doc doesn’t pick amitriptyline over sertraline because of cost.

If my septuagenarian patient lost her appetite, I’d worry about vitamin B12 deficiency, anemia, hypothyroidism, congestive heart failure, constipation, UTI, gallbladder disease, hepatitis, stomach cancer, esophageal stricture, esophageal cancer, or depression long before cervical cancer.

The morals to the stories are valid: children in general, especially family members, shouldn’t serve as interpreters; any healer has to be alert to the patient’s sensitivities, every human being deserves respect, every culture has its strengths and weaknesses.  Be careful with language barriers.

I have cultural sensitivity. And now I have the credential, regretfully bogus.

Gandhi, the Whiskey Rebellion, and Obamacare

November 22, 2015

The farmers were put to the test

By the Feds, who thought they knew best

But the solution was risky

For those who made whiskey

When they expanded off to the west. 

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 working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

This summer I worked in Pennsylvania in the area of the Whiskey Rebellion.  I took the time to read the Wikipedia article.

My high school American History course treated the Whiskey Rebellion as a joke, taking about 3 paragraphs, alleging that the disturbance ended with not a shot fired.

The Articles of Confederation gave the country a weak central government, and the new nation foundered with poor law enforcement and inadequate revenues.  Native Americans increased violence on the borders, perceiving, understandably, that the invading Europeans (and unwitting Africans) lacked effective military.  Thus the country dispensed with the Articles of Confederation and adopted the Constitution.  And Congress quickly passed a tax on whiskey.

The tax imposed a disproportionate burden on small producers, located at the time mostly in the rural and western areas.  The big distillers supported it.

In Western Pennsylvania the small distillers held rallies and staged marches, and discussed long and hard whether to use violence.  They tarred and feathered some tax collectors, and besieged others with gunfire and loss of human life, mostly on the part of the rebels.  Eventually, George Washington himself led a force of 5,000 Federal troops to Pittsburgh, and the insurrection melted.  Those soldiers never fired a shot.

At the end the Federal Government had enforced laws not only for taxing whiskey but also for conscripting troops.

The Whiskey Rebels either quit distilling, moved, or paid taxes.

(As a sidelight, the failure of the Whiskey Rebellion jump started westward expansion, when the small distillers moved outside the US, illegally, into Indian Territory, alcohol softening up the resistance of the Natives.)

But the distillers in Kentucky didn’t protest or march.  They just kept on distilling.  I suspect that threats of violence or bribes resulted in the Feds having literally no tax collectors for the state.  And the moonshiners still conduct their business, quietly and profitably.

The Affordable Care Act (Obamacare) effectively hijacked the US medical system, and things have gotten very bad for doctors.  Any doctor who participates with insurance or Medicare/Medicaid spends an inordinate amount of time on clerical duties with no improvement in patient care.  We have four choices:  comply, move, quit, or stop taking insurance.  I hear repeated calls from the doctors, up in arms, that we need effective leadership.  And I hear lots of whining from doctors literally counting the days to retirement.

I look at Gandhi’s civil disobedience and at the Whiskey Rebellion and at the ACA and I think that the docs have put themselves down the wrong road.  We need to stop clicking boxes and take care of patients.  If enforcement becomes impossible, we could win.

Badly kept residency records, and Canadian license

November 17, 2015

On the list I’m making the checks,

I sent for my scores from the FLEX.

There’s loads of email

But the process could fail

On the training of the feminine sex.

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 working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I find myself in the process of applying for a Canadian license, specifically for British Columbia.

I want to experience the Canadian system first hand, and compare it to the realities of the current US system.  Then I want to write about it.

That Canada has a national electronic credential depository called PhysiciansApply.ca makes sense.  I suppose I should have looked more carefully to find the SHARE DOCUMENTS button.  Today I found it and used it.

I don’t blame them for wanting letters from my employers for the last three years, documenting scope of practice and hours.  But how would that work if I had been self-employed during that time?  Actually, I was self-employed during that time; I got pay checks from the locum tenens agencies but as an independent contractor.  Positive they didn’t want me verifying myself, I sent emails off to the agencies.  All of them.

In the summer of 1979, I took a 3 day examination called the FLEX in downtown Denver, Colorado.  About 250 well-educated doctors came together in a cavernous hall.   All the other tests I’d taken up until then counted for nothing more than practice.  I remember that every 45 minutes or so I would have to put down my pencil and shut my eyes for 30 seconds so that I would start caring about the test again.

The Canadians want the original score from that test, and I suppose I can see their point.  I got that task done with a brief Internet search and a credit card outlay of $70.

The licensing process may very well fail on the faded records from my residency.  I had 18 weeks training in Obstetrics, but gynecology didn’t warrant any kind of mention.    And the College of Physicians and Surgeons of British Columbia wants to make sure I had adequate training.  Even though 90% of what I learned then is now incomplete, hopelessly out of date, or just plain wrong.

I spent a long morning on the phone and at the computer, making calls, leaving voice mails, asking for letters and certifications.  Without exception, the Canadians I talked to were polite, friendly, professional, and well-trained.  Their gentle reassurance carried the message that things would be fine, and my license will happen.

I keep an open mind.  If this adventure doesn’t work out, something else will.

I lunched with a colleague who works ER.  I picked his brain for stories of real major trauma.  While we talked about medications, management, techniques and tools, we couldn’t escape the discussion of drama, irony, and tragedy in the face of human bodies damaged by the inevitable truth of physical laws.

 

On Chest Tubes and ATLS

November 15, 2015

I studied up for a test

That involved a tube in the chest

For the old and the young

When collapsed is the lung

That treatment, life-saving, is best. 

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 working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I drove south to Kansas City for the Advanced Trauma Life Support (ATLS) course.

In medical school, I saw exactly one chest tube insertion, involving the “best chest surgeon in town” (in retrospect, either bipolar or alcoholic but more likely both).  I watched the surgeon make repeated jabs with a scalpel into the chest of an unanaesthetized late adolescent man who had come to philosophical terms with his upcoming death from cancer and just wanted to die comfortably. I observed the screaming and the torture for as long as I could.  When my vision contracted down to a tunnel, I knew I would faint, and rather than do so at the patient’s bedside, I forced one foot in front of another down the hall to the dictation desk behind the nurses’ station, laid down, and fainted.

The experience put me off chest tubes, but chest tubes can make the difference between life and death when a lung collapses (pneumothorax) or blood pools inside the chest on outside the lung (hemothorax).

The first time I did the ATLS course we used live, anesthetized dogs and cats to practice endotracheal tubes, venous cut downs, and chest tubes.  It bothered me then and it bothers me now that the animals did not survive our education, but the experience of the dying 18-year-old bothers me more.

I got out of the Emergency Room.  My certification lapsed, decades passed and the century turned before I needed that credential again, when my work in remote locations brought me to ER coverage.  In December of 2010 I took the ATLS again.  We used manikins for practice, not living animals.  Venous cut downs had almost disappeared.

I do not regret never having to use those skills.

Now that I stalk the locum tenens trail again, some facilities want the credential, and I discovered, to my chagrin, that mine lapsed a year ago.

Venous cut downs, the last ditch to get IV access, have disappeared in favor of a technique that bores into a long bone, called interosseous.  Endotracheal tubes continue.  The scopes still use incandescent light bulbs, having failed to progress to halogen, they may skip directly to LED but will more likely be replaced by the video Glidescope by the time I recertify next, in 4 years.

The chest tube practice manikins continue to improve, providing a closer simulation to a live human than a cat or dog ever could.

I hope I never have to use my skills.

No such thing as a free breakfast

November 15, 2015

Uncle Sam sure lied to me
And paid me a much smaller fee
I didn’t know what I’d get
Because I’m a vet.
Still, free breakfast just wasn’t free.

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, two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.
On Veteran’s Day, Bethany and I went out to a chain restaurant that offered a free breakfast to veterans. I brought my VA card.
Ankylosing spondylitis kept me out of the war in Viet Nam. Later on, when I sought to enter the Indian Health Service, I believed them when they said that I could only get in if I went as a Commissioned Officer (they lied); ankylosing spondylitis would have disqualified me, but a report from a shaky radiologist sealed the deal, saying “no evidence of sacroiliitis.”
The Department of Defense (DoD) controls 5 of our Uniformed Services (Army, Navy, Air Force, Coast Guard, Marines), but not the Public Health Service (PHS) or National Oceanographic and Atmospheric Administration. My service in the PHS qualifies me for Veterans’ benefits at the VA, and the VA has been very good to me.
In fact my IHS service units had Civil Service employees working the same job as Commissioned Officers. They got overtime past 40 hours a week and started with more than twice the base salary. All in all, my naivete cost me more than a quarter million dollars early in my career, but the value of my VA benefit is catching up. And I count my time as a Commissioned Officer as priceless.
There is no such thing as a free breakfast.

Working On My Canadian License

November 10, 2015

They have no reason to trust,

To verify is certainly just

They’ll get verification

For each certification

And fill out the forms, well, I must.

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, two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

After a surprise two-day stint in Pennsylvania, I returned home.  I had a good conversation with a doctor in southern Alaska; I had signed up for a couple of weeks but hadn’t had a phone interview.  At the end of the call, I decided that the frequency of major trauma and cardiac arrests would put the assignment outside my skill set.

I discovered to my horror later in the day that my Advanced Trauma Life Support (ATLS) certification had lapsed 6 months ago, and, without that credential, I couldn’t have accepted the job.

I got on the net and the phone and I located a course in Kansas City, with one opening.  I took it, but, strangely, I’ll have to pay by check.

I also worked on my Canadian application.

I have three web accounts going: one with the British Columbia agency that can put me in touch with facilities needing my services; one which serves as a depot for my credentials; and one responsible for a BC license.

The third account assigned me a user name consisting of a 12 digit number.

I have had to upload a copy of my medical school diploma, my Iowa license, my residency certificate, my board certificate from the American Board of Family Medicine, and certified copies of my passport, along with recent photographs.  Each professional credential required a face sheet and the payment for a Source Verification Request.

Two weeks ago I sent a packet with those papers.  But copying outsized documents like medical school diplomas and board certificates and residency certificates leaves things out, they said, and I would have to resubmit.  Along with the face sheets.  But I could do so electronically.

Confused by parts of the websites, I call frequently.  I talk to polite, professional, helpful, knowledgeable people.  They admit that some parts of the process don’t make sense, and they help me through it.

In the 21st Century, they shouldn’t trust anything I say nor any of my documents; I understand the Source Verification Request business.  I look forward to the time when I can just send my CV and pay an investigation fee.

And I’m not complaining.

My most recent US state license involved my submitting the same information electronically 4 times and by registered mail 3 times.  And the people I dealt with on the phone weren’t nearly as polite as the Canadians.

If it’s not a problem, it’s not a problem

November 8, 2015

I couldn’t do any good with medication
I thought I would try education.
I said, “Now you’re full-grown
You can just leave it alone.
Avoid, if you can, operation.”

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.
When I get permission to write about patients, I usually say I won’t mention age or gender, but I like to talk about diagnosis. For the first patient of Halloween, however, I switched. I requested and received permission to mention age and gender and only vaguely refer to the problem.
Just looking at the active 71-year-old gave the diagnosis. But the diagnosis didn’t compromise function, and fixing it would have led to months of recuperation. Doctors only have four things we can do, I said. We can medicate, operate, educate, and manipulate. And none of those will improve your function. And with surgery, we always have a chance of making you worse. If it’s not a problem, I said, it’s not a problem. And trying to fix it will take you out of work.
We had a good discussion on second-stage careers. We both face problems of trying to slow down but not wanting to stop. We both revel in the activity, challenge, and socialization of work. And we both face the challenge of limiting hours in the face of high demand for services. And we both sometimes over-commit.
I recounted my experiences with a patient at another clinic, a mason who worked well into his 90’s. When I knew him, his personal integrity brought such high quality to his craftsmanship that he could charge whatever he wanted for her services. But by then, he didn’t work for love of money. He picked his jobs by the size.
As the day wore on, respiratory infections dominated the diagnostic landscape, with skin problems coming in second. An x-ray showed a fracture, another didn’t. I took out ticks, whole and by the piece. I laughed out loud when a patient referred to a particular horse as a “tick magnet.”
With so much Lyme disease prevalent in the tick population, any engorged tick, or tick bite of unknown duration gets presumptive Lyme disease treatment.
At the end of the evening, I drove country roads back to the hotel, hyper-alert for deer going into rut. When I walked past the front desk, the clerk asked me if I were a doctor today. When I figured out he viewed my scrubs as a costume, I laughed. Yes, I said, I’m a doctor today, and I was a doctor yesterday. And I took chocolates from the bucket on the counter.

Back in Pennsylvania, Urgent Care and a Transformed EMR

November 6, 2015

It’s an updated, revised, EMR

In the last five years it’s come far

But down the wrong road

It’s as slow as a toad,

It can push a doc towards the bar.

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 drove the large rental car away from the airport into the Pennsylvania countryside. A simple transposition of two numbers for my phone contact with the hospital led to confusion and tension.
I stopped into a UPS store. As I walked in, the clerk looked up and said, “Here for fingerprints?”
“How could you tell?” I asked.
“The piece of paper you’re carrying,” he answered.
The new inkless technology contrasted to my last fingerprinting 5 years ago in Barrow, Alaska; everything about the northernmost point in the US qualifies as a unique experience.
Finished with fingerprinting, I figured out the phone number, got ahold of my contact, and entered the right address into my GPS unit.
Fall colors dominated the forests, and cute furry animals like deer, possum, and raccoon littered the country roads with their lifeless bodies. A few cornfields retained a trace of green, but most stood dry and ready for the harvest. Huge round bales of hay lay scattered over alfalfa fields. It felt a lot like home in Iowa, but agriculture here has to deal with a more and steeper hills.
The GPS took me to an address having nothing but buccolic pastures. I followed the properly named road another mile and came to a new-loooking medical building.
The Urgent Care clinic has its own CT scanner and MRI machine, but rarely used for same day studies from Urgent Care. I had a good conversation with the doc there. He showed me around, praised the nursing staff I’d have the next day, and walked me through an electronic medical record system I’d worked with while in private practice.
But this version suffered from updates and looked nothing like what I remembered. It boasted spiffy colored graphics but shuffled and gimped like a zombie. I took notes, and, at the end, I drove back to a Chinese buffet, ate large, came back to the hotel, and slept hard.
The next day started off busy, and the EMR became even more truculent than I could have imagined. It suffers from a counter intuitive, chaotic layout. It runs slowly, with plenty of 15 second click-and-wait features.
With incomplete documents piled well into the double digits, I got a call from an ER doc who talked me through the trouble spots, and as the patient flow lightened, the annoying data entry sped up.
I finished my charting on time, leaving at 9:00PM sharp.
The stress of learning a new EMR system took a toll. I remembered back to the time when the Practice Formerly Known As MIne made the conversion from paper. The steep, six-month learning curve took me well outside my zone of comfort. Halfway through the process, I had a second glass of wine on Friday night while at supper with friends, and not before nor since has my wife has seen me consume alcohol under stress. She doesn’t remember it. I do. But I didn’t have a drink when I got back to the hotel. It would have ruined my sleep.

A sudden call, an urgent need, and a trip east.

November 5, 2015

The Canadian woman looked nice

I said the doctors here seem in a trice

She nodded and listened

While our system was dissened

The regulations come at a price.

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.

On Monday evening I got a call from a recruiter, naming a town where I’d worked that had a sudden need.

Despite the morbid curiosity, I decided I didn’t want to know the drama and irony that had led a colleague to back out of a commitment to work. I recognized the name of the town, I’d worked there before and I enjoyed it. I could walk from the hotel to the clinic.  I found a good hot breakfast in between.  But within a few hours, I realized that the town had the same name but the job pertained to a different clinic altogether. I said no.
My favorite recruiter asked me to please take the assignment. By way of loyalty borne of our good relationship, I accepted. A flurry of emails followed. I spent four hours filling out forms.
My five-year-old scanner printer stopped working. Which led to a great deal of frustration. Eventually, I photographed six documents with my cell phone and sent them via text.
The next morning found me on my way back to Pennsylvania. I had slept poorly, staying up late trying to get the paperwork taken care of.
At the airport in Chicago, i sat next to an attractive young woman. I glanced at her passport and said “Canadian, eh?” She chuckled. I told her that I was in the process of applying for a Canadian medical license, and she was surprised to learn about the frustrations of American doctors with ou current system. They boil down to four: electronic medical records, the meaningful use mandate, medical malpractice, and loss of autonomy.
She could not believe what I told her about the meaningful use mandate. Congress allocated funds for doctors to purchase electronic medical records, and gave them a small incentive to use them. Then, to provide proof that they were being used in a meaningful fashion, the Center for Medicare Services formulated meaningful use regulations, to be phased in over several years. Meeting them costs inordinate hours and has cut productivity of primary care doctors across the board by 25%.
And the regulations keep getting worse.
The conversation turned into a monologue and a rant, if not an outright Jeremiad. But she listened politely, and boarded her plane when called, I think with relief.