Archive for August, 2018

Talking Canadian Licensure With a Canadian

August 31, 2018

To her home the doc wants to go back

It took time, but she’s facing the fact

She has nought left to prove

So she decided to move

I told her she just needs to pack

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I had a good long phone conversation with a Canadian national, a physician working in the States considering going back home, for a lot of reasons.

Right now she attends patients in a high-crime area with brutal heat and humidity, in the sunniest part of the sun belt. She loves teaching, and she loves medicine.

She talked about her aging parents in Ontario. She asked me about scope of practice and professional climate for docs seeking licensure in Canada.  And how to go about the process.

Honesty seized me. I couldn’t talk about her specialty or academic medicine at all. I could barely talk about big city medicine.  I told her how much I loved my spot in northern British Columbia and what huge hassles I’ve been through to work in Canada.

I couldn’t tell her what difficulties she’ll find getting licensure in Ontario, because Ontario is not British Columbia. After all, my Alaska license came easily, my Pennsylvania license did not.   She will not face the 5 months of ricocheting emails caused by hard-to-read signatures on 35-old-residency certificates, nor another 5 months of frustration caused by accidents of history in the development of Family Practice training.

She probably won’t face a 7-month dead-end with a private recruiter.

She won’t need a work permit because she’s Canadian, and she probably won’t need a physical.

We swapped bits of our backstories. I talked about how my curiosity got me north of the border to start with, but how the practice climate keeps me coming back.

We talked about how the insurance industry and government (under the guise of Medicare) used the Electronic Medical Record systems to steal the joy from medicine. We face rapidly expanding nets of regulations that demand more work but do nothing for patient care.

In the end, we agreed that we love the work despite the administrative hijacking.

When I hear American physicians whine, I tell them they can move, quit, go to Direct Patient Care (where the doc gets paid out of the patient’s pocket), keep whining, or just lay back and take it.

The Canadian internist arrived at the same narrow list of choices, and decided to move back home.

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Physician, anthropologist, and bike mechanic

August 28, 2018

In on a cycle she rode

Out to the car park I strode

I helped out her knee

With a Sharpie, you see

And stayed true to my bike-fixer’s code

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission

People in my generation have lived with gravity long enough that we all have arthritis somewhere, mostly in the knees and back.

I attended to a particular patient (who gave me permission to write more than I have) with joint pains; she mentioned she rides a bicycle a lot.

I said, “Chances are if your knees hurt your bike seat is too low, and if your back hurts your bike seat is too high. Let’s go out and have a look.”  On the way past the front desk, I picked up a Sharpie.

A long time ago in an ER far away, a young man presented with knee pain. I looked at him, noting his footwear.

At the time, some cyclists used toe clips. Few used the cleats that lock the foot onto the pedal.  I asked the usual questions, and when he’d moved his cleats.  Then I disappeared for 30 seconds and came back with a 6-inch crescent wrench.  “I need to see you ride,” I said.

His machine came close to the finest that the early 1980s could offer. (If you must know, a Reynolds 531 frame with Campagnolo components.)

I had him ride once around the parking lot, and when he got off, I used my wrench to raise his seat 8 millimeters. He later wrote me a letter that his knee pain evaporated within hours.

Fast forward several decades. Bicycles advanced as bodies aged.  My 21st century patient’s mass-market vehicle had some wonderful components; I adjusted the seat height without a wrench.

After three successive approximations and three laps around the parking lot, marking calibration with the Sharpie, she rode with her leg almost fully extended at the bottom of the stroke, and declared her knee already improved.

Not relevant to the medical problem at hand, but part of my bike-mechanic ethos, I fixed her rear brake.

The human leg’s last few degrees of extension, the most efficient and the ones we use the most as we walk, involve an exquisite locking mechanism that lets us stand with no more energy expended than sitting.

She rode off into the late summer morning, I returned to the chilly, air-conditioned clinic, reveling in the synthesis of skills: physician, bike mechanic, and anthropologist.

The front desk staff stared at me.

“I fixed the problem,” I said, and returned the Sharpie.

 

 

Not even a pound

August 19, 2018

Here’s a few things I can tell

This fellow has really aged well

He’s past decade 9

And he feels just fine

And his speech is clear as a bell.

 

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

On the brink of leaving for the weekend, I saw one of my many 91-year-old patients.

The town has a lot of people who have aged well; they have maintained physical vigor and mental sharpness beyond threescore and ten. Partly because of genetics; partly because of community brakes on tobacco, alcohol and drugs; and partly because this particular generation has continued hard work since before WWII, I have the honor of caring for people with a perspective on the human condition that only age can give.

Most of these patients take few medications, despite the fact they’re walking around with artificial hips and knees. A lot of them have atrial fibrillation (now in common American parlance as afib, thanks to drug company direct-to-consumer advertising) and high blood pressure, but a lot of them don’t have diabetes, which I attribute to the town getting a lot of collective exercise, mostly in the form of daily chores.  Very few have depression.

Yet I have detected a trend towards the re-emergence of Parkinson’s disease, characterized by tremor and rigidity of movement and thought. When I finished training in 1982, the vast majority of Parkinson’s came from the 1918 influenza epidemic.  I thought Parkinson’s would evaporate with the death of that generation, but in the last 5 years I have noticed one or two elderly per week with the pill-rolling tremor, loss of facial expression, quiet and monotonous speech, shuffling gait with poor arm swing.

So if I mention a vigorous patient, still employed, in his 90s, with no Parkinson’s symptoms, I have released no identifying information, as so many of my patients fit that description.

And if I say I made a surprise diagnosis via CT scan showing a serious but treatable, potentially life threatening problem, I could be describing dozens of patients.

I could mention a marriage of 70 years duration but I might be referring to any one of a number of town inhabitants.

But this particular patient has not gained a pound since he finished high school, a very unique circumstance. He gave his permission to mention it, and the rest, in my blog.

 

House call=the opposite of telemedicine

August 3, 2018

Let me tell you a story that’s tall

This gig that I’ve got is a ball!

For symptom description

Won’t suffice for prescription

And I get to make a house call!

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Current sociologic forces will undoubtedly lead to telemedicine, which I feel compromises patient care.  Doctors don’t get into trouble by examining patients, they get into troubled by not examining patients. Thus when requests for prescriptions by phone arrived, I asked to see the patients.  For a multitude of legitimate reasons, two could not come in.  With a morning schedule of only 3 patients, I readily agreed to make house calls.

I love making house calls.  I get out of the clinic and the hospital and experience the patient’s context.  And I always get a few breaths of fresh air.  The patients always appreciate it.

As the morning wore on, the three patients on the schedule became 4, then 5; not a heavy clinc load, just a good, solid pace. And by the end of the morning, I had two seriously ill patients in the ER.

I run a lot of CT scans, and most of them come up normal. The majority of the rest come up abnormal but with abnormalities best ignored.  Half of those with abnormal scans showing problems needing treatment will, for one reason or another, agree to the treatment; about half will not.  And of those, few require treatment the same day.

But in fact I found myself talking to consultants in Sioux City, requesting they accept a transfer. Later, concerned about the growing cascade of delays, I asked how long the ambulance would take.

I don’t remember the last time a patient transfer via ambulance went smoothly or well.  I suppose the problem is inherent in the ER genre. When one patient left our ER in an ambulance and started down the road to Sioux City, I inhaled the relief, then moved on to the next patient.

I asked for help from the emedicine in Sioux Falls  Perhaps telemedicine, but with the all-important physical exam.  I texted a specialist friend for some advice. The patient stayed in the ER close to 3 hours, but got handled in town, without needing transfer.

Emergent patient care precluded lunch at the scheduled time, so at 1:00PM I bolted for gas station fried chicken 3 blocks away, and took it to go.

I tried and failed to relax while I ate, and, sure enough, just as I finished the last bite the nurse came to tell me about the first afternoon patient.

Still, I finished the 3 scheduled afternoon patients. When I looked at my electronic inbox, the last two names seemed vaguely familiar, and then I remembered my two house calls.

And on a fine summer day, the nurse and I set out with an administrator, who knew where we were going.