Archive for May, 2017

I heard “20” used as a verb

May 31, 2017

The patients with brains that disturb?

We don’t kick them out to the curb

We can keep them from harm

With the medicine’s charm

And here we make 20 a verb

 

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, about to get a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Over the course of a quarter century, I got used to rising before 6:00AM, so that I could round at up to 3 hospitals and arrive at clinic in time to see patients starting at 9:00AM. Eventually I found I moved much more efficiently in the mornings, and as the decades went by my physiology embraced the change into a morning person.

I still get up early, even when I can walk to work at one hospital and round under the same roof where I do clinic; even when I don’t have any work in the morning. Today, before I could go to work, I had to stop at the bank and open an account.  I needed the account so I could pay for professional liability insurance automatically.  The bank didn’t open till 9:30.  So I felt like I was playing hooky.

The extremely personable young woman at the bank looked at my passport and did a double take. “You’re an American?”

I nodded. “I thought my accent would have given me away,” I said.  Although, because it hadn’t, I suspect that my accent is changing without any conscious effort.

I deposited most of my cash. With the exception of the Laundromat, I have been able to do all my transactions via credit card.

But the 8 page form for professional liability insurance asked for all the professional liability carriers I’ve had. Thirty-five years of medical practice has included a lot of carriers, as well as 8 years of coverage by the Federal Tort Claims Act.  I called Bethany; we compiled that data last year for credentialing elsewhere, and within an hour she’d found it.

At noon I walked over to one of the Chinese restaurants.

All medical facilities need meetings so that small problems don’t become big problems. In the Indian Health Service, the entire hospital did nothing but meetings on Thursdays.  Other places allotted an hour, usually over lunch.  When I worked in Utqiaviq (the Inuit village formerly known as Barrow) we met every weekday for an hour.  In more than one place, I got to see the dysfunction that results from eliminating weekly doctors’ meetings.

Today I joined the medical staff for their Tuesday meeting. We started at 3:00PM.  The laughter and warmth that filled the room for the next hour could only come from a group with extremely high morale.  I didn’t have much to add; as a locums I could genuinely say that I don’t have a dog in the fight.  But I got to ask a number of questions.  One of which followed the use of 20 as a verb.

A “20” refers to involuntary hold when psychiatric factors render a patient dangerous to themselves or others. I learned about the process of how to make it happen.

All societies have an obligation to take care of their mentally ill, those disabled by a dysfunctional thought process.   Free societies must balance personal rights against the need to protect people from the psychotic.  Most states limit the time the physician can hold a person against their will to 48 hours, this part of Canada allows for 72 hours.

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Bear season: the people can fight back

May 30, 2017

Out here we’ve plenty of bear.

But we go out whenever we dare.

We won’t bring to ruin

An innocent bruin.

So we lock up our dumpsters with care. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, 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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, about to get a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Right now this part of British Columbia finds itself in the middle of bear season, meaning that for a few short weeks the people get to fight back. All the dumpsters in town have bear-resistant closures and signs that urge the lock up, because “A fed bear is a dead bear.”  I find no open trash barrels anywhere; those containers have a very clever opening system too small for a bear to get a paw into.

With as many of the bruins as inhabit the area, I would expect more conflicts with the people. Such, however, occur rarely.  The ecosystem also supports mountain lions, wolves, coyotes, moose, elk, and deer.  Though few people talk about hunting elk, many talk about moose and caribou and deer.  Surprisingly few talk about bear hunts.

I still don’t have everything I need to start seeing patients. I must obtain professional liability insurance, and to do that I must have a bank account for automatic withdrawal.  And none of the banks were opened today.  I got the form filled out, with the exception of that one number.

So tomorrow I’ll come in after 930AM, when the banks open.

I started learning the Electronic Medical Record (EMR) system, my 15th in the last 30 months.  I enjoyed seeing Mickey Mouse appear as the test patient; he has played that role in a lot of EMRs that I’ve learned.  Some places have his correct birthdate, May 15 1928.  They list his spouse, Minnie, and some include his felinophobia (fear of cats) on the problem list.  His medication list has included citalopram (an anti-depressant) more consistently than any other medication.

I heard that a doctor put together this EMR, but I don’t know how to verify that assertion. If so, I can hope that it functions.

It will have to be very good to beat New Zealand’s MedTech32.

I’m licensed in British Columbia

May 28, 2017

They don’t give out my license on paper

I hope it won’t turn into vapor

For it’s up in the Cloud

And now I’m allowed

To take the next step in this caper.

 

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 then I’ve worked a few times each in Alaska, Nebraska, and Iowa; I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, about to get a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I haven’t written about my progress getting licensure in Canada since October 2015, when I sent my packet to PhysiciansApply.ca. Much has happened since, and the hypothetical start date kept receding like a mirage.  About the beginning of this year, it got fixed at May 29.

With no exceptions, every Canadian I’ve talked to has been polite, friendly, and helpful; if not knowledgeable they knew exactly the person for me to talk to. I suspect that the bewildering regulations frustrate them as much as they frustrated me.

I flew into Vancouver Thursday for the last 2 items: my work permit and my license. I took a risk coming to the airport without the work permit, but I needn’t have worried.  The polite, friendly immigration officer at one point reassured me that there was no way he would send me back, as I had made it my mission to help the people of northern BC, and I had all my documents (about a centimeter thick).  I had budgeted the entire day for the process, but he had me out before 1:00PM, on my way to a nice hotel room, where later I would toss and turn the entire night, wondering what the face-to-face interview with the College of Physicians and Surgeons of British Columbia would be about.

Rural health facilities find recruiting doctors difficult. While a lot of doctors can be happy with their work anywhere, most docs (not me) have spouses who prefer the amenities of bigger cities.  Though, strangely, early on I rejected a couple of opportunities in Vancouver.

Again, I needn’t have given so much energy to the interview process. It went smoothly and professionally.  I learned about the licensing process for BC, the strictness of the rules involved with the time allotment.  And I got to talk about my goals.

American doctors love to hate the Canadian system that American liberals love, and neither knows much about it. I want to find out about it from first-hand experience, and to be able to discuss it intelligently.

And the moose hunting is way better in Northern British Columbia than it is in Iowa.

Thus I found myself Friday morning walking away from a beautiful building in the heart of a vital, bustling, energetic city with my provisional British Columbia medical license not in my backpack but somewhere up in the cloud. The College of Physicians and Surgeons of BC doesn’t give out paper licenses anymore: they send an electronic file.

It felt a little anticlimactic, but any effort stretched over two years with thousands of emails would.

 

 

 

How did those samples find me?

May 11, 2017

The samples can help people quit
Without the nicotine fit
Tobacco detox
In a little brown box
Came free, and it made quite a hit.

 

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

About ten days ago I found a box on my desk, sturdy cardboard, about 6 inches on a side. It held Chantix samples from Glaxo, Smith, Kline.
I hadn’t asked for the samples, I’d signed no papers for them, and I have no idea how GSK knew where I am. After all, I’ve only been here since February.
And they were the right samples to treat exactly one patient: a starter pack, because abruptly starting full dose Chantix risks major side effects, and two months follow-up therapy. Chantix turns out to work better in real life than it did in the lab; it works more consistently than anything besides quitting cold turkey.
The first patient of the day came in for other things (and gave me permission to write what I’ve written). But just like I do for everyone else, I asked if he smoked.
And, indeed he does.
I used to lecture people on the evils of smoking. By now, though, everyone already knows all the bad things about tobacco. Lecturing only brings antagonism into the relationship; “educating” the patient can thinly mask judging the patient.
These days I use a script from Motivational Interviewing, a technique that capitalizes on ambivalence. I hold my two forefingers a foot apart, and I ask, “On a scale of 1 to 10, where 1 means you’re not ready to quit, and 10 means you’re ready right now, how ready are you to quit?” If they say 1 or 10, I stop. For any other number, I ask, “Why not 2?” Mostly the smokers don’t get the question, and will tell me the bad things about tobacco. I interrupt them, explain that they weren’t ready for the question, and ask them the 3 best things about tobacco. When the patient understands what I’m asking, they mostly talk about stress relief, anxiety, and habit. A few talk about taste. One said “Breakfast, lunch, and dinner.” After they tell me their favorite things about tobacco, I give them a blank stare for 3 seconds, then change the subject. The idea of Motivational Interviewing is to get the patient to think.
But this patient gave me an enthusiastic 10. I don’t get many of those, just like I don’t get many 1s. And he’d done well with Chantix in the past. In fact, he wanted me to give him a prescription for Chantix. “I’ll do better than that,” I said, “I will give you the Chantix.” And 90 second later I reappeared with the samples.
He already knew how to use them, and he already knew about side effects.
I couldn’t think of a more appropriate way to use the samples. Tobacco makes any other medical problem worse.
I enjoy helping people, but certain parts of my work bring me disproportionate pleasure. A low B12, a high TSH, or curing someone by stopping their statin makes my day.
This one came close.

Reflections on medical frauds

May 8, 2017

The system is inherently flawed

They want me to sign and to nod

They have no excuse

It’s all billing abuse

And I’ll say to their face, “You’re a fraud.”

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Sunday I visited a web site that promised to cure my tinnitus. It had all the marks of snake-oil fraud: heavy reliance on testimonials, repeated themes that the establishment didn’t want the product to succeed, recounting hard-to-believe medical horror stories for those that relied on established medical practice, and at the end the assertion that the narrator didn’t want to make money, he only wanted to do good for the world but mainstreamers would soon make him take down his website because of jealousy over his success.  Those tools exist because they work, and they nearly worked on me.  I wanted to believe.  But I knew if the narrator really just wanted to help people, he would have made the audio download available for nothing, and relied on contributions to keep the website up.

Towards the end of the video the phone rang. I listened to the robot,  pressed one, and told the live operator, “Your prerecorded announcement said I got the call because I’d responded to a TV back brace commercial.  Is that right?”

“Yeah.”

“How can that be? I don’t have a television.”

The line went dead.

This morning when I dove into my IN box  I found 4 faxes from a physical therapy operation in a nearby town, wanting me to sign off on very general orders for patients that I didn’t know and certainly hadn’t examined. I called the number at the bottom of the sheet, and spoke with a secretary who explained that the firm had a direct access program.  I tried to explain, in turn, that I could not in good conscience sign off on a patient with whom I had had no contact.  But as Mark Twain observed, it is difficult to get people to understand if their jobs depend on them not understanding.  I turned the papers over to our clinic manager.

Yet I also got a similar order sheet for medical supplies, and I checked with the staff; the doc whose place I’m holding indeed orders those supplies yearly, and I signed.

Our country has an enormous amount of medical fraud; vendors interested more in profit than patients buy a lot of late-night TV commercial time, and some people call in to get scooters and other durable medical goods. Over the years I had a lot of requests to sign off on knee, back, elbow and shoulder braces, none were needed.

Yet a few vendors offer diabetic supplies at greatly reduced cost. So I can’t just shred all the requests.  I have to read each one.  After all, the fraudsters only copy successful business models.