Archive for January, 2017

Executive order puts me between jobs

January 31, 2017

A federal hiring freeze

Has put my plans into a squeeze

It was signed with a smirk

But I just wanted to work,

For the Vets with a cold or a sneeze.

 

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, the fallout of certain Presidential Executive Orders has me cooling my heels at home . Any identifiable patient information has been included with permission.

Usually Washington decisions take months to influence my life, the ship of state does not turn on a dime.   But one of our new President’s Executive Orders, the federal hiring freeze, which garnered the least attention, impacted me the most.

The original plan, to return from Alaska, kick back for a couple of weeks, then return to Alaska to work with the VA, got derailed shortly after the inauguration. Especially because we have a family event in Pittsburgh the last weekend of April, the VA’s requested minimum 90 day commitment has lost its feasibility.

Emails to my planned employer have gone unanswered for a week and a half now, and it’s time for me to move on. Even if I know that winter in Alaska leaves most medical installations short-handed.

Working locum tenens taught me to embrace uncertainty. What happens in reality turns out better than what I had planned.

Back in 2010 I tried to book employment on my own, without an agency. I sent a mailing out to 25 nearby facilities, following up with 25 phone calls and 25 emails.  I got no response.  Since then all my work has been through agencies.  And I would have gone with an agency to the VA but for some shifts in budgets and Federal rules.

A good agency justifies their piece of the pie by value added services; a bad agency has difficulty justifying their existence.

(As a side note, my Canadian venture started with 5 months with an agent who didn’t work out. I struck off on my own, and 18 months later got a job offer.)

In the meantime I’ve been doing Continuing Medical Education with the American Board of Family Medicine, trying to keep me, and them, up to date; I got 56 hours that way. I’ve been doing some Canadian CME, too.  I read the journals that stacked up in our absence.  I go to the gym on alternate days.  I take a nap when I feel like it, several times a day.  I made 4 batches of moose jerky.

I had a novel in need of rewrites on my hard drive; I did 5 edits and submitted it to a publisher.

But I need to go back to work. I miss it.  I have an agent (more accurate than the commonly used term recruiter) looking at spots in Alaska, northeast Nebraska, and southwest Iowa.  Another agency offered a hospitalist spot in New Mexico.

Bethany and I go to movie matinees. We talk a lot about where we might go next.

 

 

January 15, 2017

At a party they come up to me

For a finger, a shoulder, or knee

What I don’t have to prove

Is that you just have to move

Not a consult, that advice is just 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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, short jobs in western Iowa and Alaska, I’m traveling right now but not for business. Any identifiable patient information has been included with permission.

More subspecialists than FPs show up to my social gatherings.  Today, in Texas, I found myself at a brunch.  Parents socialized and 21 children behaved like children.

I got called just as I finished my omelet.  By name and kinship status, they said, Someone needs you.  No surprise.

I stood, I followed.  One EMT in particular seemed to know where she was going.  Around two corners and…No, no injury here.  The staff said, go downstairs.  Which we did, all 8 of us in search of someone to be rescued.

We spread out around the pool.

Nope, no injuries here, either.

Back up to the lobby, where the clerk chided us:  With all those children running loose, someone is going to get hurt.

Well, better a false alarm than a real injury.  Really.

Later in the day, in a much smaller group, I talked with someone about a finger problem, and demonstrated “muscle energy” as a technique to improve range of motion.  Emphasizing the need for slow progress over sudden change, I cautioned gentle exercise 3 times a day for 3 weeks.  And we talked about the problem of disuse.

Right after that someone with a shoulder problem asked about a supplement consisting of curcumin, the active ingredient in tumeric.  I said, “Is it working?”

I asked the same question of the man with knee pain earlier in the day; he wanted to know about glucosamine/chondroitin.

Both told me that, yes, it helped, but they wanted to know if they benefited from the placebo effect.

Don’t knock the placebo effect, I said.  Though I didn’t get the chance to add that 60% of the patient’s improvement comes from the patient’s expectation for improvement.

Then I told both the story of a friend of ours with an allergy to overeating.  If he eats too much he gets hives, and, as a consequence, he doesn’t overeat, and over the decades we’ve known him he has slowly lost weight.  In a case like that, with a disorder so rare, we’ll never be able to generate really good data on treatment.

In an informal situation, with no record being made, I didn’t get into the depth of the problem.  I didn’t seek the answers to the 2 key questions: what does the patient’s illness mean to the patient?  Why did the patient get sick?

But the person with the shoulder problem had the real answer to 90% of musculoskeletal ailments: continued activity.

 

 

 

 

Meeting the VA’s New Rheumatologist

January 11, 2017

I drove through the snow to Sioux Falls

The place with the old red brick walls

Where it seems it’s the norm

For the staff to be warm

To the vets who walk down those halls.

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and assignments in western Iowa and southeast Alaska, I’m back home. Any identifiable patient information has been included with permission.

I heard this joke in 1982: You walk into the patient’s room in the VA and there are three glasses of orange juice on the bedside table.  What’s the diagnosis?

The punch line goes, “Patient died 3 days ago.”

Fast forward 20 years.  Having suffered for more than 30 years with chronic back pain from ankylosing spondylitis (much like rheumatoid arthritis but affecting the spine) I had started the miracle drug Enbrel a year prior, and finally got an appointment with the Veteran’s Administration rheumatologist in Sioux Falls, South Dakota.

Please do not judge the VA on the delay of care. I separated from the Public Health Service (along with National Oceanographic and Atmospheric Administration, the two uniformed services that no one knows) with such anger that I divested myself of certain papers. After the critical regeneration, booking a first-time rheumatology appointment took the same 6 months that it would in the private sector.

I came unprepared for the warmth and caring that flowed from everyone in the institution. I certainly did not expect two secretaries on their lunch break to help a clearly disoriented vet wandering the hallway, nor to do so with such kindness.

Since then I’ve driven once or twice a year back to Sioux Falls to meet with the rheumatologist. Every month or so I get a refrigerated container in the mail worth about $2,500.

The routine includes a lab appointment; if scheduled for 9:00 I can count on being done with the blood draw by 9:02. I have watched the system acquire bits and pieces of efficiency, until it happens as fast as possible without rushing the patient.

I’ve not had a morning doctor’s appointment previously. The blood test itself takes an hour to run, and I can only imagine the clockwork precision behind the scenes.

I sat down to wait. I napped.  I read a medical journal I’d brought from home.

I chatted with another vet, one of the moral giants who regularly walk the corridors there. I saw a lot of modified heroes.  In the last 15 years I’ve seen the number of women vets steadily increase.

A nurse came out to tell me of the doctor running behind schedule. I told her I understood patient flow, especially in a raging blizzard.

The doctor apologized to me for the delay, too, before anything else. I’d not met her before.  Young, energetic, and kind, she has a quiet competence about her along with the extraordinary intelligence that  permeates the subspecialty.

We both spoke well of the rheumatologist who preceded her during his semi-retirement, and I thanked her for coming to the VA. We agreed that telemedicine might be the future in a few specialties, but not in rheumatology.

Not until I explained my ankle problem in medicalese did she ask, and I told, of my status as a physician.  After that things went much faster.

I spoke briefly of how much I liked locum tenens. But I didn’t give details, so as not to make the next patient wait longer.

Where I’d walked into the building in low visibility, I walked out in bright sunshine. A fierce north wind which ruined gas mileage on the trip up sped me on my way home.

 

More Like Have a Nice Vacation Than Saying Goodbye

January 8, 2017

If not normal, what could it be?

I can think of a horror or three.

I don’t try very hard

And those thought I discard

But this time, I know what I see.

 

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

 

Between patients my nurse asked, “Did you see that outside?”

I looked out the window. “It’s snowing,” I said.  “In January.”

“But it never snows here!” she said. Indeed, this island in the Japan Current rarely gets so cold that the precipitation falls as a solid.

I have come to another last day of an assignment. I worked here in April, and enjoyed it.  But they only needed me this time for their holiday vacation coverage.

The upcoming Tribal Council Inauguration had shifted the clinic routine, with the last patient scheduled at noon today. But the Council postponed the ceremonies out of respect for the family of a suicide.  That tragic event got splashed across Facebook.  I know no more than the general public knows about the case, and, considering a few insiders, I know a good deal less.  I won’t write about it.

But in a community this small, where everyone knows everyone, I started to see the medical fallout within 48 hours. Two of my 9 patients today would not have gotten sick but for the stresses and chaos from that suicide.

The island has a strep epidemic going. We now have clinical criteria, the Centor Score, which takes into account age, fever, tonsillar exudate (if you prefer, pus), enlarged lymph nodes, and absence of cough.  I have asked for rapid strep tests on my sore throat patients, but, after examination, if the patient has fever, big lymph nodes near the jaw, pus on the tonsils, and no cough I prescribe penicillin (to the non-allergic) no matter what the test shows.  Our facility ran out of injectable penicillin, though, a week ago.  But as I read up on the subject last night, the main preventable complication of strep, rheumatic heart disease, dropped below less than one case in a million 20 years ago, and the CDC stopped keeping statistics on it.

Four of my 9 patients had sore throats today. More had coughs.  Towards the end, people start wishing me well, but it felt more like telling me to have a nice vacation than saying good-bye.  I’d like to come back again.

I make a living out of thinking of the worst thing possible.  It’s something I do with every patient.  Mostly I delete the catastrophic stuff from my consideration, but today I went ahead and got an x-ray which should have had a low chance of being productive.  I waited as long as I could for the radiologist’s report, but as the hum of the clinic faded to a whisper, I went ahead and ordered the MRI because I couldn’t deny I’d seen a shadow where I shouldn’t have.

I put on my jacket and slipped the cleats onto my boots. I stepped out into the driving snow.  As the fat, wet flakes melted on my face, I hoped I was wrong.

The Risks of Patient Transport: playing games of imperfect and incomplete information

January 6, 2017

Blog 2017 January 5, 2017

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

In private practice last century, I got a call from a mother of a sick child late in the afternoon. Despite a tight schedule, I told her to bring the kid up, now, and I would attend to the problem.  In a hurry, and in traffic, her car collided with another.  No injuries resulted, but since then I have always kept in mind the risk of patient transport.

Many Alaskans live in places inaccessible by road. You can get there by plane, train, or boat, or, in winter, by snow machine.  Rivers thus become highways, not barriers.  The geographical imperative colors medical decision making.

Game theory forms the basis for making a lot of choices, and medicine becomes a microcosm of the human condition. Any course of action carries a risk, and, at the same time, not taking that action carries a risk.  As physicians, we deal with the real world when we play games with incomplete and imperfect information.

Consider, for example, a hypothetical patient in alcohol withdrawal. At first evaluation, I would generate a CIWA (Clinical Institute Withdrawal Assessment) score based on temperature, blood pressure, pulse, sweating, agitation, irritability, restlessness, memory, and overactive sensations of touch, hearing, and sight.  In Iowa, where transport to the hospital carries almost no risk, a score above 8 would mean hospitalization.  But here, a score of 25 would make me consider sending the patient to Ketchikan by boat.

Not so fast. If the wind keeps the floatplane from flying, it whips up whitecaps on the water.  I would have to consider the risk of drowning 5 people.

I also have to consider the risk that the patient, once stabilized in the Ketchikan ER to a score less than 8, might be discharged to the streets.

In such a case, I would do as much as I could (in this example, fluids, vitamins, and sedatives in the family that includes Valium, Xanax, and Ativan), keep the patient in my ER, and, if I could get the CIWA score under 8, get twice daily follow ups for a couple of weeks.

When we refer patients out, they usually go to Ketchikan, but our obstetrics patients go to Sitka. Major illness requiring subspecialists could go to Seattle or Anchorage.  And every transport carries a risk.

Avoiding Windows 8 in the Morning.

January 5, 2017

I don’t want to install Windows 8

The function just isn’t that great

But before I begin

I must dodge once again

An update I try not to hate.

 

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

My computer gets turned off at night, either by someone or by power outages. Come morning I face a powered-down machine, and I have to make a cold start.  This week, turning on the power button resulted in a 3 minutes wait and a demand to install Windows 8.

Our facility runs on Windows 7 Professional. I’ve worked with Windows 8 and found it balky and undependable, and, if I can believe what others say, the fault comes from the system.  Yesterday I undertook the same series of useless maneuvers three times before I could boot up Windows 7 Professional.

When I worked in Navajoland, my outlying clinic had power outages on average, 6 times a day, which effectively ruled out computerization. I had hoped to be the last computer illiterate member of the Yale Class of ’72, not buying my first machine till the late 80’s.

I’ve learned some things in the interim, including the universal Microsoft fix: turn it off, then turn it on. And if that doesn’t work, I know to call the Information Technology specialist.  Every health care institution now has one.

So after three unsuccessful laps around the wrong track, I walked out to the nurse’s station and asked for the IT number (the listed one got me Housekeeping, and however much I was tempted to ask if she had a trashcan large enough for my computer, I didn’t). One of the more computer-savvy nurses offered to have a look at it for me.  She punched the button that would have led to installation of Windows 8.

I gasped. My heart in my throat, I desperately reached for the power button, which, to my horror, didn’t turn the computer off.  Till I held it down and counted to 5.

A crowd gathered in my office, which eventually included the IT specialist. But by then, for unknown reasons, the Windows 7 Pro version booted up.  Luckily, I had witnesses.

The IT maven shook his head, took a seat, went to the control panel and did things that I didn’t understand.

Then, because the first patient of the day canceled, I chatted with him and the Nurse Practitioner that shares my office.

The NP had an independent practice for a couple of years before he came here. We volleyed horror stories of Epic, Cerner, and Centricity, but he had good things to say about PracticeFusion, the system he used.

I opined that every Electronic Medical Record system loses functionality with every update.  The Indian Health Service purchased the VA system and named it RPMS.  In the last 25 years, no one has tried to improve it.  Thus it still works.

Useless Recertification: it’s not just for doctors any more.

January 4, 2017

The process I do to maintain

Certification is too hard to explain

The Board, corrupted by powers,

Just wastes my hours

And puts dollars right down the drain.

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

The physician community at large carries a grudge against Maintenance of Certification (MOC).

I suppose I agree with the general concept: that truth has a finite half-life, and that skills not continually updated deteriorate. Thus, during my radio career in 60s and 70s, my Third Class Radiotelephone Operator’s License from the FCC never needed updating, and, to the best of my knowledge, is still good.  Because I’ve not done broadcasting for almost 50 years, and because the nature of the job must have changed, it probably would do no good.

I knew a doc in Sioux City who got his Internal Medicine Board certification the last year it represented a lifetime ticket; after that all the internists had to take an exam every 10 years. He retired the same year I first went walkabout.

Family Practice, from its inception, embraced the concept of keeping current with an exam every 7 years.

The real world involves mission creep.  The American Board of Family Medicine (ABFM) has made the recertification process increasingly Byzantine.  A rep from that Board, at a Continuing Medical Education lecture said, in so many words, If it takes you more than 5 minutes to figure out what you need to do, call the Board.  There are well-trained people standing by to help you.

Too polite to express outrage, none of us said, “If your process has to be explained to people who take tests for a living, it’s too complicated.”

Eventually, when things got bad enough, the doctors rebelled. The American Board of Internal Medicine made the MOC process so complex, time-consuming, and expensive that a group of physicians broke away, formed their own Board, and went into competition.  The ABIM immediately apologized to its members, and backed off the requirements.  For a lot of docs who had hit an emotional tipping point, it was too little, too late.

The ABFM simplified things two years ago, but not enough to allow description in less than 500 words.

I talked to a patient involved in electric power generation (he gave me permission to write more than I have). At one time he held 8 professional certificates, but his work morphed so he let some tickets lapse one by one.  And none of them came cheap.

Bethany, a professional educator by training, is using her time here to complete her Maintenance of Certification. Which boils down to a lot of busy work, a needless expense, poorly worded tests with marginal validation, and has never demonstrated a benefit for anyone except those who charge her for the privilege.

But you could say the same thing of the recertification process for Family Practice.

Chickenpox, and cannabis hyperemesis syndrome

January 3, 2017

The patient came down with some spots

All over, in multiple crops.

So I called up the State

To tell them this date

To watch out for chickenpox.

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

I saw a patient with chickenpox today (and received permission to mention it and more in my post). Though outbreaks came a couple of times a year last century, the varicella vaccine has made the diagnosis a rarity.

The characteristic lesion starts out as a red bump. The bump grows a blister, characterized by the poetic catch-phrase “dew drop on a rose petal.”  Then follows a pimple (doctors say pustule), which collapses in on itself (medicalese=umbilication because it looks like a belly button), and scabs over.  To make the diagnosis, the patient has to have multiple crops of lesions, coming successively over the course of several days, visible in various stages of healing.

A very small proportion of those vaccinated, less than 1%, will develop the disease from the shot, sometimes a year afterwards. Among the vaccinated, 5% will get chickenpox if exposed to the wild virus, but the infection may be so light as to be unrecognizable.

Still my strong suspicion and the public health laws made me call the Alaska State Epidemiologist, and I found out that, in fact, the illness is currently circulating. In the end, I based my decision not to medicate on the number of days elapsed since onset and the desire for the treatment not to be worse than the disease.

I saw two cases of cannabis hyperemesis syndrome today; if a person smoke a large amount of weed for a long enough time, they start to vomit and very little can help them besides stopping the marijuana. I went to my favorite physician’s social media site, Sermo, to research the problem and found, to my surprise, the tendency of those so afflicted to crave hot showers and baths.

I saw two men with astonishingly similar injuries from astonishingly similar circumstances.

One patient came to me after a specialist work-up and MRI and many, many primary docs over the years failing to help. I listened without interrupting. I came to a much different conclusion, and advised that the dentist had a better chance than anyone of fixing the problem.  At which point the patient told me the diagnosis.  Not in medical terms, but in plain English.

 

New Year’s Day, walk on the beach

January 2, 2017

We went for a walk on the beach

To see what the ocean could teach

Then the tracks of mink

Made us question and think

As the eagles in cedars would screech.

 

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

 

Being a couple of well-established party vegetables, we retired New Year’s Eve at 9:30, only to be awakened by fireworks at midnight. We could see most of them from the bedroom window.  Bethany opened the curtain, we put on our glasses and lay in bed, watching.   The display went on for a quarter-hour.  Bethany drifted off to sleep.

The sun rises late here, not till after 8:30. We went out for a walk on the beach with one of the pharmacists.   The island has diverse geology, and resistant rock outcroppings break up the strand.  Pacific flotsam dots the high-tide line; the most colorful parts I found were ropes, nets, and plastic containers.

We spotted an immature eagle soaring. We walked on the sand when we could, but mostly we slipped and slid over shingle, the pebbles and cobbles on their way to becoming sand.  We clambered over interesting layers of granite, layers turned vertical by unspeakable geologic forces.

People walk their dogs on the beach here, we expect to find canine and human tracks in the sand. But we also found a lot of lynx tracks, and we could read a dramatic story of a large cat stalking a very small deer, but the novel’s end got lost where the sand merged with the broken rock.

We heard the skittering, high-pitched call of an eagle in a towering cedar, but couldn’t spot him.

And we came across the distinctive, delicate marks that mink paws make in the sand. In one spot we found the shell of a sea anemone apparently retrieved from a tidal pool at low tide by a mink and consumed on the spot.

Then we found 3 drag trails, each paralleled on one side by mink tracks, each coming up from the jumble of stones and puddles of water and erratically but inevitably leading up the beach, past the high-tide line and into the rain forest and muskeg. We followed as best we could.  Though I track well for my age and demographics, I couldn’t follow the trail on the rock or on the spongy floor of the forest.  We wondered how many mink constituted the party, and what they had caught.

When we had gone as far as our aging knees, ankles, and backs would take us, we turned around. The wind died down, the sunshine warmed us and we unzipped our jackets.  Against an astounding blue sky we spotted eagle after eagle, gliding from the water into the trees.

 

An MD who acts like an osteopath

January 1, 2017

There once was a doctor named Still

Who wanted to cure more than bill

He went out on his own

For the crunching of bone

But retained the scalpel and pill

 

 

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, traveled 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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

In 1874, Andrew Taylor Still, MD founded osteopathy.

At the time, before the acceptance of the germ theory of disease, philosophical schools divided medicine. Allopaths, the dominant force, felt that illness came from outside the body.  Homeopaths felt that illness came from inside the body.

Still felt that illness resulted from a misalignment of the boney elements of the body, but embraced the scientific method and rejected dogma.

Time has marched on. Homeopathy gave rise to our discipline of immunology and our approach to allergies, but in 1954 Hahnemann University School of Medicine officially stopped being a homeopathic school.  Mainstream US medicine still calls itself allopathic, but recognizes autimmune diseases and medical problems arising from internal disregulation.

Osteopathy continues, distinguished only by teaching and use of osteopathic manipulation.

Michigan State, my medical alma mater, has programs for MDs and DOs. While I have an MD degree, my class was the first to cross the tracks to get instruction in osteopathic manipulation.

In fact, in my first undergrad career I had a roommate who had had a roommate who had been in chiropractic school, and via that long chain of learning, I acquired the skills to manipulate the spinal column. But I got those skills without the rest of medical school, so that I learned to manipulate without learning when or why or why not.  Yet, to the best of my knowledge I never hurt anyone.  I got a lot of practice on the young and the healthy.

(Daniel David Palmer, the founder of chiropractic, probably attended Still’s Osteopathic college in Kirksville, Missouri, for a short time.)

Osteopathy along the way evolved an approach to the patient that I find a good fit. The body, a complex system, functions as a unit.  Ask why the patient got sick before asking what you can do for the symptom.  Maximize the patient’s natural tendency to heal, and do your best not to interfere with it.

I still manipulate, but I recognize those who manipulate better than I do. I like to say that some chiropractors get better results than others, and if I don’t know the local talent pool I say so.

Yesterday I brought my skills into play, got the satisfying crunch so easily as to be humorous, and made the patient better before she left. (And she gave me permission to say more than I have.)

And the same day, I got praise for being thorough, digging through the layers of physiologic dysfunction to figure out the root source of the illness.

Both of those patients benefited from the osteopathic approach, more obvious for one than for the other.

In the 21st century, more and more MDs do manipulation, at a time when more and more DOs leave it behind.   And more and more of the non-subspecialist physicians, regardless of training, take a holistic and humanistic approach to the patient as a whole human being.

I saw profit motive build a bridge between the doctors and the chiropractors, when the docs own an MRI and want the business.