Archive for December, 2015

Christmas? Easy. The day after? Difficult transport

December 27, 2015

For ambulances, we have only two.

The blizzard came out of the blue

It stormed and it snowed

All the way down the road

That’s the reason that nobody flew.

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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Christmas went quietly, and I only write that after the fact because I don’t want to jinx myself by saying good or bad when people ask me how the call is going. I always say, ask me when it’s over.

I used to work at a place which regarded the holiday as lasting 5 days, with me on the hook for 120 continuous hours. The second year I started with a census of 38 hospital patients  At the end, with a grand today of 20 hours of sleep, my work quality had degraded significantly in that I had quit caring.  The following year I absolutely refused to carry the beeper for more than 72 hours.  Management voiced their objections, which I noted, and used the phrase “patient safety” in my reply.

I don’t work there now.

So far here in Nebraska I haven’t worked more than 50 hours a week. When I go home, I go home.  The term “call” carries no meaning; I have no beeper and they expect me to turn my phone off at night.

I finished my Christmas work before noon, went to the gym, and got back home in time for lunch.

This morning, the day after Christmas, I went in to make hospital rounds and staff the Saturday clinic. I crept down icy asphalt, a strong north wind threatened to blow me off the road.  Just as I pulled into the parking lot snow started in earnest.

I can’t talk about individual patients but I can speak to the aggregate: all could remember the start of World War II, and all could remember the Armistice Day Blizzard of 1940.

One patient had improved enough for discharge.

The medical end of the discharge process came easier than the EMR. I ran into a 16 item set of blocks requiring responses.  I clicked in a couple of places, got no response, muttered in Navajo (the only per se taboo words have to do with the government), clicked again and nothing happened.  Eventually I asked for a consult from the ER doc.  By the time help arrived I figured out that my computer had locked up and needed restarting.

One patient, having failed to respond, required transport to Omaha, but the weather had worsened to blizzard conditions and no one would fly. The town has two ambulances, one had yet to return from a transport in the wee hours.  So my patient’s transfer would have to wait for a loaner from another community or the return of our other ambulance.

I looked outside at the whiteout, and I thought of Barrow, where weather prevented flying an average of 1 day out of 3, and the flight would last a minimum of 5 hours. The ground transport to Omaha would last a fraction of that, with several other hospitals along the way if the conditions worsened.

Saturday clinic welcomes walk-ins but has no appointments. I saw my first patient at 10:15AM.  I have gotten enough fluency with NextGen that the documentation flowed.  I took care of 5 out patients.  One had an alarming physical finding I’d never seen before.

At the end of clinic I bought delivery pizza for the skeleton crew. We usurped the conference room and chatted.  When I walked out, the snow had stopped but the wind, if anything, had freshened.

I didn’t have to scrape the windows.

 

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Christmas Eve, finishing at noon.

December 26, 2015

I don’t mind that the other docs leave
A balance I hope to achieve
And they’re closing at noon
The time off is a boon,
I’m happy to work Christmas Eve

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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I work the holiday weekend because I don’t celebrate the holiday and I want those who do to have the time with their families. With two exceptions, I’ve done so every Christmas since 1975. Our facility made the decision to close at noon on 12/24/15. One of the permanent docs has already left for vacation.
I came in a bit early to care for a patient admitted yesterday through the ER.
Then I went back to my office to find no one on the schedule until 10:00.
I waded through a backlog of documentation that preceded my entry into the EMR here, NextGen. After two weeks in the system, I got full access this week.
I took the delay with equanimity. If I can’t get a piece of information or do a particular task, then I can’t. Management treats me very, very well here, and hasn’t overloaded me. If I eventually need to stay late to play with the semi-conductors, I get paid.
NextGen has a particular button to push, called PAQ. Because no one seems to know what that stands for, I’ve started calling it Pheasants and Quail, and until Tuesday, every time I clicked it a message appeared saying the provider was disabled, good for a few jokes. Yesterday the button started to function for me, giving me 118 of my own documents, plus x-rays, lab tests, letters, and consultations to approve.
As with most EMRs, NextGen has its share of irrational quirks. I don’t know another system that makes the doctor approve his or her own document twice.
With exactly one patient on my schedule, I cheerfully took another provider’s patient who showed up 45 minutes late. I had a good time talking with the patient and the family; we developed a plan and I completed the electronic paperword about the time the next patient, in the pediatric age range, got through screening.
I carry a yoyo because I take care of children; a really spiffy one because I can. I did a few tricks, involving a couple of mistakes, but impressed the family and the patient. At the end I said, as I usually do, “If you don’t smoke, drink, or use drugs, you can afford any yoyo you want.” I see it as a way to guide concrete-thinking children towards good lifestyle decisions.
A family member held up a thick envelope, expressed frustration that nationally recognized experts hadn’t helped, and requested I take the case.
I said I’d be happy to, but the more doctors that failed before me, the smaller the chance that I would succeed. “Make an appointment,” I said.
That documentation finished at noon, I went back down the hallway to the hospital and conferred with the patient and family. Terms like the 2 midnight rule and the 3 day stay rule flew back and forth. Eventually I said, “I understand the synthesis of porphyrins, but I haven’t been able to grasp the insurance company’s rules. Because they don’t want their rules to be understood. There is no transparency.” And I left the question up to the nurse who would talk to experts working Somewhere Else.
Bethany waited for me in my office when I returned. We sweated in the gym for an hour and went out to lunch.

Life-changing events. Some teeter-totters don’t balance.

December 24, 2015

The trials that people have had
Happy? More often they’re sad.
Sometimes it’s cancer
And the patient will answer
When I break the news that is bad

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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I cared for people today who had survived life-changing events.   I dealt with medical problems ranging from the mundane to the dramatic, but, as a writer, I wondered about the details of those moments.  Each of those events rippled through family and social structures, and had ironic and desperate consequences.  If I would write that sequence, whether as fiction or in exposition, I would want to know the details: weather, sounds, colors, smells, lighting, furniture, and clothing.  What part did surprise play?  How far did the consequences go? I don’t ask those questions; the patients have come for medical problems which may or may not relate to the original injury.  But sometimes they want to tell their story, and when they do, I listen.

I don’t interrupt. I nod my head.  I make eye contact.  Occasionally I raise an eyebrow.  Some of the narratives carry more interest than others, and some narrators give a more coherent and cogent narrative than others.  And I get a lot, but I only pump for details on the illness: quality, intensity, location, duration, modification, and context.

In ranching country, I see the consequences of livestock-related accidents. And most of those involve the hands. Rodeo cowboys in particular tend to lose fingers and pieces of fingers, trapped between saddle horns and ropes.  And a surprising number of people have survived gunshot wounds, again, most maim digits.  But the culture here pushes people to “cowboy up” and keep going, and  mostly, they do.

One of my patients today came in with such a complicated history I spoke not only with the primary care doctor but two specialists. I ordered a bunch of blood work and some imaging, and concluded that some teeter-totters can’t be balanced.

Along with listening techniques, I have ways to give bad news, something that every doctor has to do.  A malignancy rarely comes as a complete surprise; I can remember exactly one cancer patient who didn’t suspect.  I can direct the conversation so that the patient says the C word first.  When I break bad news, I listen intently to the words pouring from a breaking heart.

They ramble, full of stories, full of the drama and irony of the human condition.

Third week in Nebraska, and it’s a great gig.

December 21, 2015

The stuff I see is acute
But there’s chronic and puzzlers to boot
I’m not fussing or kicking
And not cherry picking
And everyone knows how to shoot.

b>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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I have a pretty good gig here.

Most of the patients have a relationship, direct or indirect, to the agricultural sector. Most patients, male and female, respond if I choose to strike up a conversation about hunting, firearms, or archery.

Yesterday I had a really excellent patient age range, from 93 years to 9 months.

I take the overflow from the permanent docs. I see a lot of colds, coughs, sore throats, rashes, aches, pains, workman’s comp, anxiety, headaches, and depression, so, to a certain extent, I am doing Urgent Care.

But the workload is such that if I see a puzzling case, I get to start the work-up and see the investigation play out. I can recommend non-antibiotic treatment and tell the patient to call in 48-72 hours if they don’t improve. So I find out when I make a good call and when I make a bad call, and my life-long learning proceeds.

So far I’ve avoided the frustrating parts of chronic care, diabetes, high blood pressure, and high cholesterol. That triad starts with bad lifestyle choices having to do with diet, exercise, alcohol, and tobacco, and leads to hardening of the arteries, arteriosclerotic vascular disease. Which in turns leads to the country’s biggest killers, heart attacks and strokes.

And my practice partners, so far, don’t mind. They feel relieved that those folks calling for same-day appointments get taken care of.

Still I feel like I get more than my share of instant gratification. I don’t like the analogy of cherry picking when it comes to taking the easy stuff in medicine; I’ve done it and I know it’s hard work. I prefer to say I feel like I’m skimming the cream, which, of course, I’ve never done so I can’t speak to its difficulty.

The lab, x-ray and nursing staff do their jobs, and I haven’t run into any passive-aggressive behavior.

I have to use the Electronic Medical Record (EMR) now, which I don’t enjoy. When I get a scribe, which I sometimes do, my life gets a lot easier.

The town has everything that I want, including a selection of Chinese restaurants.

We have a lot of non-Spanish speaking Hispanics here, and I don’t know why.

Another EMR, and a Parkinson’s patient improved.

December 19, 2015

A tremor after the Great Flu
Is Parkinson’s, we already knew.
There’s more! Please just wait,
There’s a shuffling gait,
And the facial movements are few.

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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Towards the end of his life, my father developed Parkinson’s disease, which eventually killed him. Ever since I’ve been alert to the diagnostic clues.

When I started in training, 80% of the Parkinson’s that we saw came in the wake of the Great Influenza of 1918. By the 90’s I could tell you from across the street who had escaped that flu (the spry) and who hadn’t (the slow movers). That generation has passed.

When most people think of Parkinson’s, they think of the characteristic “pill-rolling” tremor that goes away when the person moves with intent. But I don’t often see that tremor. I look for facial expression that doesn’t change much, a stiff, shuffling gait, and very small handwriting (micrographia). I listen for monotonous, quiet speech. I inquire about loss of sense of smell (anosmia). I feel the muscles between the thumb and forefinger while I talk tot he patient, which will show the beginnings of a resting tremor long before it becomes visible.

Today a patient made my day with Parkinson’s visibly improved. I had made the diagnosis relatively early. The voice had more music, and the small, involuntary facial and hand movements had returned. Much work remains to fine-tune the medication.

I now have access to the current EMR, NextGen, the 7th EMR I’ve learned since January. I have left off dictating my records like I did in the first two weeks. The computer gets in the way of patient care, but complaining about it does no more good than honking one’s horn in a traffic jam. Nonetheless I worked three unscheduled patients in, and for each one I spent a good deal more time entering data into the computer than I did with the patient. I’ve had lots worse EMRs here in this country (New Zealand’s, MedTech32, stands as a shining ray of hope that we could have a good system), but I have had better, too. It doesn’t stick very much. When I run into a click-and-wait, it doesn’t last more than 20 seconds. Sign on takes less than 3 minutes. But it has design flaws. The button to sign off sits in the top left corner right next to the button used to clear one patient’s chart and move to another. Every drug for every patient comes with a warning, mostly frivolous, but a lot like the boy who cried wolf.

The clinic won’t have it much longer, Cerner will replace it in February.

A blizzard? Maybe not such bad luck.

December 16, 2015

It’s winter, and wouldn’t you know
It’s time for the wind and the snow
With the luck of a wizard
We had us a blizzard
And I handled it just 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. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I broke a tooth chewing on a slice of dried mango, and asked around the hospital for the name of a dentist. Good luck brought a 7:30AM appointment next day, bad luck brought a blizzard that night.
I started early next morning but cleaning the car and creeping down the ice-covered highway with low visibility took time.
I don’t mind going outside in the cold. Last winter, in Nome, Alaska, I cheerfully walked a kilometer to and from work. I frequently walked in the ditch, to get away from traffic, and when I finished that part of the walk, I climbed out.
But I mind going into a ditch if I’m in a car.
Still I attended to my hospital patient before dawn, put in orders, put off writing the note, and went out into the snow.
The temp had warmed up so that two inches of fat, wet flakes covered the car in a half hour. I brushed and scraped the car again, and crept down the hill into town.
In this sparsely populated area of the country, the dentist has a lot of out-of-town patients, and he faced a schedule full of cancellations. If I could get the prep work for the crown done that morning, it would cut my time away from clinic, and would help fill his schedule.
We saw it as a win-win situation.
I dozed in a state-of-the-art dental suite while he drilled and lasered, and walked out an hour later with a temporary crown to find 4 inches of fat, wet flakes covering the car. The white stuff came down so fast that it covered the armrest inside the door in the short time it took to put the brush in and seat myself.
Patient flow slowed to a crawl in the clinic.
I discharged my inpatient before lunch, and learned I could get free chili or chicken noodle soup in the cafeteria.
The cafeteria here doesn’t sell hot food to employees, but has a bank of 5 vending machines with a microwave, and the offer of hot soup came as a pleasant surprise.
I took care of a total 3 patients in the morning session and 3 patients in the afternoon session. My access to the EMR, NextGen, came through, and I have started the odious task of mouse clicking. I remained thankful to the blizzard that I didn’t have more time pressure while on the steepest, lowest point of the learning curve.
We closed early, at 4:00PM. I went outside to clean the car off, but the wind had picked up and the temperature dropped, so it went easier than the three times before. Visibility improved, and I arrived back at the townhome ahead of schedule.
I would have preferred a commute short enough to walk, but I benefited from very good dental services. I would have preferred better weather, but I got the work done in a timely fashion without cutting into my schedule.
Maybe the blizzard wasn’t bad luck after all.
Life is full of tradeoffs.

Double vision, remembering Wernicke’s without Korsakoff.

December 15, 2015

So double, the patient did see
That he came to the clinic to me
I think, I’m not sure
I can come up with a cure,
Just a shot of Vitamin B

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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I attended a patient here with double vision, and I had good cause to think back to another patient I’d cared for out in the Alaska bush. On physical exam, his inability to keep his eyes looking in the same direction struck me as nothing short of dramatic. In the next week, the mystery unfolded. With neurologic consultation and MRI, he turned out to have Wernicke’s encephalopathy, a thiamine (one of the B vitamins) deficiency from excessive alcohol consumption. A vitamin shot or two cured him, and the experience frightened him into sobriety.

I recounted my experience to the patient here. Before firmly establishing a diagnosis, I started thiamine therapy, first by injection and then by mouth. As we have no MRI yet, and the neurologist comes only once a month, I set up both. I arranged those things with less desperation because we have wonderful weather, with services accessible by highway. And then I got on the Internet to research Wernicke’s encephalopathy.

They taught us in med school to look for confusion, double vision, and ataxia (loss of position sense), but in fact later research showed that only 10% of cases include all three parts of the triad. So often does Wernicke’s go with Korsakoff’s psychosis or amnesia that doctors tend to speak of Wernicke-Korsakoff as one word. The diagnosis comes up much more often in autopsy findings than in clinic, indicating we miss all but the worst cases.

Without saying where or when, I told the patient here about my experience with a case of Korsakoff’s, where the patient got stuck in one day, and, despite 3 months therapy for another illness, never got past it.

The patient agreed with me that Korsakoff’s would be the worst complication of alcoholism, more frightening than death from cirrhosis of the liver.

(Oliver Sachs, the brilliant neurologist-author, wrote a detailed account of a patient with Korsakoff’s in his book, The Man Who Mistook His Wife for a Hat.)

Nebraska: Second week

December 13, 2015

Is it real, a drill or a fake?
An exit we always must make.
The alarm would require
In event of a fire
In any case, it gives me a break.

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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

The hospital here has a marvelously functional system, but I’m not sure it would scale up to a larger institution.

If a patient comes through the ER in the middle of the night and needs admission, the ER doctor does the history and physical and writes the admitting orders. In the morning, either I or the patient’s usual attending physician assumes care. I get to turn off my cell phone at night; if I have an admission, I’ll find a message on my voicemail in the morning. I don’t carry a beeper.

As in most winters, the respiratory disease season has started. I diagnose a lot of viral illness, and I do a lot of explaining why antibiotics in these situations cause more problems than they solve.

Most rashes that I see come from viruses, most will go away with no treatment. Pityriasis rosea (PR) stands as an exception.

The typical history of PR runs something like this: a large red patch cropped up from a few days to a few weeks before the rest of the rash broke out with elliptical lesions whose long axis follows lines of skin cleavage, giving rise to a “Christmas tree” distribution on the back. Light cases don’t itch. If the patient receives no treatment the problem will go away. In six weeks. Until a year ago I had thought no treatment would shorten the duration of PR, but an exceptionally good Continuing Medical Education (CME) session in Pittsburgh brought the news that acyclovir can stop the problem in less than 2 weeks.

But I didn’t see a case from then until I came here. I’ve made the diagnosis more than once, and it pleased me to no end to start the new medication.

***

I arrived Wednesday at 7:20AM and started my morning routine. I had just hung up my coat and started the sign-in process when the fire alarm went off. I grabbed my jacket, closed my office door, and closed exam room doors all the way down the hall till I could step out into a brilliant glorious morning.

I looked south over the town, through the crisp, clean air, at a few pure white clouds against the bright blue of the Sandhills sky.

Two workman, dressed in blaze orange vests, were starting their day. After a few moments savoring the outdoors I asked, “Do you know if it’s a fire drill or the real thing?”

Their heads jerked up and they stared at me. They asked, “Did the fire alarm go off?”

I nodded.

They looked at each other and then sprinted past the temporary CT trailer to the back door.

I made my way around to the employee crowd at the main hospital entrance. “All clear, Code Red,” sounded before I could ask about a real fire.

Two hours later, the fire alarm sounded again. My Medical Assistant wanted to go about her duties, but I insisted that we leave immediately, donning my coat as we went. She closed exam room doors on one side and I on the other. Just as we got out of the building the alarm stopped.

I thought back 11 months ago, when the fire alarm sounded in Nome and everybody in the hospital went into the parking lot at -15F. Most of us grabbed our parkas. The air there, too, was clean. The frozen Bering sea gleamed white, and the mid-day sun hung low in a pure blue sky.

No matter how much I love my work, I welcome a break to go outside.

Unattended Patients: first week in Nebraska

December 7, 2015

What will the hospital do,

To equally assign to the crew

And not hurt the workers

Who make up for the shirkers

Who dodged the call that they drew

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, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia.  Right now I’m in western Nebraska.  Any patient information has been included with permission.

 

Sometimes, people who don’t have a physician, or who don’t have a local physician, need hospitalization.  As time has gone on, I’ve seen shifts in the way that hospitals approach the problem.  Every hospital where I’ve worked made privileges contingent on willingness to care for those patients on a rotating basis.

The move to staff hospital ERs full-time started in the 70’s, and I can remember a very good ears-nose-throat specialist putting on a set of scrubs to take the night-time duty.

In residency, the ER doctor would open up a box containing 3×5 cards with the name and phone number of every primary care doc in town, take the card at the front, call the doctor in question, and move the card to the back of the box.  We referred to those patients as “box calls,” and OB had a separate rotation.  Some docs took the system with more equanimity than others, and, as always, the workers resented the shirkers.

When I came into private practice, both hospital ERs maintained a list on the bulletin board next to the emergency doctor’s work station.  He or she would make the call, and cross the name off the list when the doc in question accepted the admission.  We called it the “hit list.”

Those patients rarely had insurance or money.   I did for free most of the care in that system, and I regarded the financial loss as part of my social obligation to do some pro bono work.  Other docs didn’t see it that way, and some invariably had a reason to dodge the hit.  I did my best to be pleasant on the phone to the other doc.  I established a good rapport and a good rep, but about every 7 years, when very tired or overloaded, I’d use my past cooperation to delay till daylight the next hit.

Those two institutions have since moved to a system where the ER doc makes the decision to admit, and the hospitalist employed by the hospital attends the patient during their stay. Fewer and fewer primary care doctors attend patients in the hospital. Alone among first-world doctors, US physicians have the option to do both inpatient and outpatient work.

Here in western Nebraska, where our critical access hospital has a staff in the single digits, I agreed to take care of the unattended admissions (here called the “no docs”).  I suppose that makes me the de facto hospitalist.  I resolved to be the best of the breed, and, if the patient has a physician out of town, to make a doctor-to-doctor call at discharge.  At the end of my first week here, I met the goal 100% of the time, in numbers barely into the plural range.

I have gotten comfortable with the inpatient EMR, I still don’t have access to the outpatient EMR.  Midweek we moved into a very nice town home outside of town with a lake view.  I face a 14-minute commute, unless I go slow enough to admire the scenery.

Faded Signatures: 4 Months to BC License.

December 6, 2015

They might think that I’ve misstated

Or perhaps I’m just overrated

This back-and-forth trial

For a license denial

Because the ink at the bottom has faded.

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  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.

This afternoon I got a call from the British Columbia recruiting agency, and my learning continues.  As it turns out, they have plenty of docs trying to come in and get jobs in coastal BC. Any installation trying to get a locum tenens doctor has to do a great deal of documentation before they get approval, worse if that doc comes from another country.  The bureaucratic hoops seem insurmountable.  But when I told her I planned to go to the northern, interior part of BC her voice audibly brightened.  I might stand a chance, but, in all honesty she said, it will probably be at least 4 months.

I learned that each Canadian province has its own Electronic Medical Record system, and if I don’t get my BC license, Alberta might be easier.

And I explained I might have a problem getting a license.

Last night I received an email from the Canadian website where I’ve sent my credentials.  They want a better copy of my residency certificate.

After 4 years of medical school, a physician who wants to practice goes to post-graduate training, or residency.  Non-surgical specialty training generally runs 3 years, surgical specialties like cardio-thoracic or ophthalmology take 5 to 7.  At the end of my term in Casper, Wyoming, I received a paper certificate mounted on wood and protected by laminated plastic.

The Canadian agency in charge of vetting my credentials so they can be reviewed by other agencies said that they’d looked at the copy of my residency certificate, and they couldn’t read two of the three signatures at the bottom.

My email back to them noted that the certificate had been faded by exposure to fluorescent light for 26 years and sunlight for 23 of those years. The signatures weren’t very legible to start with, and I couldn’t do better than the professionally-made copy I’d sent.

In the 21st Century, due diligence demands verification of all credentials.  The hours of investigation easily justifies the Source Verification Request fee I’ve already paid.  They should not just take my word for it.

I still face the hurdle of poor documentation of my gynecologic training during residency.

But I have a tiger by the tail.  Every application I fill out asks if I’ve ever been denied a license or if I’ve ever withdrawn an application.  So far I’ve answered, in honesty, “no.”  Withdrawing an application reflects badly on me.  But license denial because of an illegible signature doesn’t.