Archive for November, 2018

Malignant materialism: Black vs. Plaid Friday

November 26, 2018

Thanksgiving? Not all that you’ve heard

And the turkey’s a much larger bird

A gift for your grad?

For Friday’s now plaid.

For the local business assured.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Canada celebrates Thanksgiving the second Monday of October. Feasts commonly include turkey, squash, vegetables, and apple pie; regional variations include salmon, wild game, Brussels sprouts, wild rice, unique local foods, and what Americans know as New England boiled dinner.

The narrative of the Canadian First Thanksgiving has to do with Martin Frobisher’s successful landing with more than a dozen ships on Baffin Island.

The US Thanksgiving holiday comes the third Thursday of November. The common story of the first Thanksgiving includes the Pilgrims inviting the Wampanoag to a meal celebrating the first corn harvest.

Not surprisingly, the Wampanoag tell a different story that sounds more likely, having to do with irresponsible celebratory gunfire, checking the wellbeing of the vulnerable English, and fishing and hunting in the process. Particularly ducks, geese, turkeys, and deer.

Deer haven’t changed but turkeys have. Since 1950, average slaughter weight has more than doubled, from 13 to 29 lb.

The holiday itself has morphed with the times; religion, hunting and gunfire for the most part have dropped away, replaced by a prolonged, sedentary feast followed by a commercial feeding frenzy. All with a prolonged football binge.

Canadians, like their southern neighbors, kick off their big retail season with the day after American Thanksgiving, calling it Black Friday.

I went to work this year when my friends and relatives in America went out of their way for arguably the biggest meal of the year.

I found it a day to be thankful, without overeating. A hospital patient went home.  I got along with my wife, my colleagues, my patients, and my co-workers.  I walked from a decent dwelling to a decent work place without fear for my physical safety.   I got to see patients improving, and I witnessed the miracle of more addicts coming to insight.

The next day my arrival in clinic started with an accusatory, “Where’s your plaid?”

“P-plaid?” I asked, noting the surrounding tonsorial color scheme indeed dominated by plaid.

Plaid Friday, they told me, celebrates buying locally.

I shrugged. I don’t own anything plaid in Canada.  My general abhorrence of malignant materialism, combined with hundreds of snow-packed kilometers between me and the nearest Wal-Mart made supporting Plaid Friday easy.

Finding myself on call till 6:00PM qualified as the biggest surprise.

 

 

 

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Fingerprinted by the Royal Canadian Mounted Police

November 22, 2018

The Constable, he offered a link

He was trained, thank goodness, in ink

A true pro, that Mountie,

He declined my bounty

And we agreed on the evils of drink.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I went to the Royal Canadian Mounted Police to get fingerprinted today.

I had my finger prints taken first in 1970 by the Sheriff’s Department in Geary County, Kansas, having been booked on the charge of Illegal Pedestrian. (Neither the Court nor the Sheriff has a record of the offense.)  The Indian Health Service required another set in 1982.

Between the summer of 2010, when the Samuel Simmonds Memorial Hospital management sent me to the police department of Barrow (now Utqiaviq), Alaska, for 4 sets of prints, and the summer of 2015, the fingerprint paradigm shifted. Instead of special ink and paper, the FedEx installation used a digital device.

(That particular installation in Pennsylvania got hacked, and all my personal and security data got leaked, including my fingerprints.)

As I’m applying for a Texas medical license, the Texas Medical Board wants two sets of fingerprints, the old-fashioned way. I had to stop by the Royal Canadian Mounted Police station.

A few of the larger cities in Canada maintain their own police forces, but most jurisdictions find contracting with the RCMP more cost-effective.

I have had nothing but favorable experiences with law enforcement in Canada. The Mounties maintain a unique blend of professionalism with friendliness.

The RCMP branch opened at 8:00AM. I had luck, the Constable had been trained in paper-and-ink fingerprinting before the digital revolution.  I had to give my height in inches and weight in pounds; we couldn’t be sure that Texas would know what to do with metric dimensions.

In the States prints cost $10 to $25, depending on quantity and agency. I reached my fresh-washed hands into my pocket for cash, but the RCMP declined payment.

I told the Constable about my adventures, and my plans to do locums with my daughter and son-in-law in Galveston on the Gulf Coast. Most people like warm climates and the Sunbelt, I observed, but my wife and I thrive in the cold.  Then I talked about wanting to work in Nunavut, the northernmost and largest Canadian territory, but nobody answers my emails.

He has connections in Nunavut, he said, and said he’d send my contact information on. After all, we agreed, not very many docs want to go there.

I left the RCMP station with a bounce in my step, impressed again by an institution that blends professionalism with friendliness. I have hope that the meeting will help me network.

.

 

Remembrance Day, without cognitive drift

November 19, 2018

Consider the dragons you feed.

When it comes to the smoking of weed

Add up the expense.

It doesn’t make sense

But neither does booze, you’ll concede

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Canada celebrated Remembrance Day last week.

In elementary school we learned about Armistice Day, and few people now remember that WWI fighting stopped at the 11th minute of the 11th hour of the 11th day of the 11th month of 1918.

Armistice Day still exists, but the celebration has morphed. The US celebrates Veterans’ Day, and Canada has Remembrance Day.  The clinic and a lot of the town’s businesses closed.  I even bought a fake poppy and pinned it on my lab coat the Friday before.

The day after, I came back to work rested and refreshed. I had a fantastic morning.

Not a single patient that I attended before noon used marijuana. Perhaps some people can get high responsibly, but the people who get sick don’t know when they’ve had enough tobacco, alcohol, or cannabis.  And now that Canada has legalized weed, heavy hemp usage has become an increasing factor in anxiety, depression, insomnia, erectile dysfunction, testosterone deficiency (“low T”), falls, and accidents.  Poor short-term memory and impaired ability to deal with numbers makes history taking and patient education problematic.  So my morning went more easily.

If a patient’s story keeps changing in terms of concrete details such as numbers, dates, and times, the cognitive drift clues me in to probable intoxication.

Alcohol and tobacco, and increasingly marijuana, of course, give me job security. I had patients that morning with insight into their problems, taking steps to deal with their addictions.

Almost every patient with an addiction knows they have a problem before they walk through the clinic door. By the very definition, an addict continues an addiction despite negative consequences.  But few realize the financial costs.  So I added up the addictive costs for a patient and came to a total over $15,000.  (That approach failed when caring for a tobacco-chewing Inuk who spent less than $100/year on the habit.)

Every patient gets subjected to observational neurology. I look, I listen, I touch, and I smell.  The basic examination of the nervous system starts when the patient comes into the room.  The neurologists will tell you that watching a person walk and listening to them talk will get you through 90% of the diagnostic possibilities.  I used those skills last week to make a tentative diagnosis, and I look forward to seeing a patient improve.

 

 

How to put 75% of the physicians out of a job

November 19, 2018

Perhaps genetic predilection

Could serve for behavior prediction

I’ll make a confession

Like those in my profession

I’m employed because of addictions.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Addictive processes have commonalities. People lose count, they lose control, they fail at trying to set limits, the addiction takes priority over health and family, adverse consequences happen but the behavior continues and continues to demand more and more time as use escalates.

Not surprisingly, addictions account for a disproportionate part of my business.

Fewer than 15% of Canadians smoke, but smokers today make up 75% of my patients.

Most drinkers smoke and most smokers drink, and, not surprisingly, most marijuana users also use tobacco and alcohol.

Long ago I quit trying to get substance abusers to admit to a problem. Most of the time I can get them to tell me about the chaos that envelops them.  When we discuss alcohol, marijuana, or meth, they generally make light of the problem, and I ask, “How’s that working out for you?”

I do not contradict the people who say, “Just fine.”

But I frequently try to get the patient to talk about their goals. And then I ask, “How does $8,000 dollars going every year to tobacco, alcohol, and weed fit in with your plans?”

Those techniques I got from a program called Motivational Interviewing, and, thanks to the wonders of the Internet, it has become available to anyone with a computer. It allows a person to capitalize on someone else’s ambivalence.

I do not expect to see the impact of Motivational Interviewing immediately; doing locum tenens I rarely see the impact at all.

But last week over the course of 2 days, 6 of my patients declared intentions to get clean and sober. Three asked to be sent for counseling, and two have already started going to meetings.

Each one of them comes from a back story of betrayal and abuse, loaded with drama and irony and promises made and broken. If they keep on the path of recovery, they will discover that weaknesses can be strengths and strengths can be weaknesses, depending on application and timing.

I hope this trend continues and spreads. Doing away with addictions could potentially put ¾ of the doctors out of business.

I hope I live long enough to see it happen.

Suffering Call: it’s not just for doctors anymore.

November 18, 2018

This town has milling and mines

And power than runs down the lines

You might slip or fall

When you come off of call

Whether working with people or pines.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Much has changed in medicine since I graduated medical school in 1979, but some things haven’t. Sick people want to get well and don’t want to see strangers.

Patients want three things from a doctor, in this order: availability, affability, and ability.

Doctors must offer services to those who need them in the middle of the night, thus my profession will always demand some sort of call scheme. My father, a cardiologist, expected to answer calls and take care of patients 24/7/365; he masked his disapproval when I revealed I regularly shared call with 4 other docs, and we covered for each other during vacations.

I did the math, counting call hours as work hours: a doctor who offers continuity of care for outpatients and inpatients, sharing with 5 others, puts in, on average, a 70 hour week in the unlikely event he or she can keep the office hours to 40.

But this town has mills and mines, and pipelines and power lines cross the area. Diesel mechanics, millwrights, pipeline management, electricians, first aid workers, linemen, engineers and even truckers all have call schedules.  No piece of equipment can run 24 hours a day without breaking down, yet the big employers all run 24 hours.

The physicians get respect here because so many of the mill hands, with or without call, work in the middle of the night. We know what it’s like.  Locally, a lot of people have call worse than the doctors’.

I see the health fallout. Sleep deprivation leads to loss of emotional resilience, which in turn compromises immune function, worsens depression and migraines, and aggravates tendencies to substance abuse.  And, not surprisingly, sleep deprived people have more accidents.  For those people on the night shift who contract illnesses that could further impair their concentration or manual dexterity, I tend to err towards back-to-work slips that give an extra night of rest.

Add to everything else the Canadian cold season. Winter’s official first day still remains 6 weeks in the future, but the snow that fell this last week will not melt till spring. We have double digits below freezing and slick roads.  Inadequately rested people behind the wheel on icy highways might not fall asleep, but minimally impaired reflexes lead to rollovers, and one of my colleagues dealt with 4 of them in one night last week.

Yet today I took care of a trucker who retired after 62 years behind the wheel, having never crashed nor gotten a speeding ticket. Because such a unique record could identify the patient, I asked for, and received, permission to write about it.

On marijuana, wages, and education

November 4, 2018

Here’s what to learn from the sages

Education is not just about wages

Your life it makes richer

For the depth of the picture

And it keeps your mind out of cages.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Medical school starts with 2 years of classroom study, with little actual patient care except classes in interviewing and physical exam. Third year brings the cataclysmic change to clinical work: one month you sit in lectures and try to absorb as much as you can, and the next month you deal with people who bleed, vomit, cry, and sometimes die.

My medical school, based in East Lansing, sends 80% of the medical students to smaller communities for those crucial two clinical years. I went to Saginaw.

At the time, the automobile industry dominated the town. Up till then I had always lived either in big cities (not my favorite) or college towns.  Saginaw changed my context radically; I ran into a lot of blue-collar workers on a daily basis.  I had left my bubble.

One of my classmates, having grown up in Michigan, remarked that one of his high school classmates started working in an automotive plant at age 18, and a doctor would have to work till age 45 or 50 to match lifetime earnings.

I recall a millwright on the internal medicine service who made as much money as the attending physician, and worked much better hours.

Fast forward 42 years, and Bethany and I have landed in a different mill town.

Bethany substitute teaches. She found the elementary students polite to the extreme.

But she has concerns about many of the middle and high school students, concerns she shares with the administration. A lot of students don’t engage in class because as soon as they turn 18 they can start high-paying mill jobs.

My grandfather had a talk with me before I went off to college for the first time. A man so wise that even as a truculent 18-year-old I recognized his wisdom, he said, “You don’t get an education to earn more money.  You get an education because an educated man leads a richer life because he understands what he sees.”

Few people have a grandfather like that, and fewer still come from a cultural background that values learning for the sake of learning.

Of the 18 patients I attended on Friday, while the season’s first heavy, wet snow hushed the town, 14 abuse marijuana, using it multiple times daily. Of those, 12 have high-paying factory jobs, and of those, 10 have chaotic homes.

I don’t know where to look for causality, to the weed, the wages, or elsewhere.

But I do not think making marijuana legal will do anything positive to engage the students in school.

 

Small non-miracles

November 1, 2018

I don’t believe in my aura

At least I don’t any more-a

I can’t tell you why

A bird will fly and not die

When I pick it up from the floor-a

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I took care of a patient today with a physiologically unlikely (but not, as it turned out, impossible) complaint. Before I had the chance to research, and while I kept my skepticism concealed, I established rapport with the patient and, in the process, learned to use a medical instrument I’d never seen before.

When the world started the change to digital, I ran into problems.  I stopped the first digital watch I bought in 1980, and kept stopping them for another 10 years.  After that they didn’t stop so much as the batteries died quickly.

When I came off the Acoma Reservation in 1985, the first electronic cash register I encountered malfunctioned at my approach.  I attributed the stoppage to the inherent fragility of new technology, but the trend continued for another 12 years.

Our youngest daughter ran into the same problems and to this day kills digital watches.

I do not believe people have auras, and thus I find it hard to account for the fact that digital devices used to break down consistently in my presence.

But, to build rapport, I told these stories to my patient, who also stops digital watches.

She has a way with animals, and she catches birds with her hands.

I recounted the time that a bird flew into our picture window, while our children, age 7, 9, and 11 watched.  The bird dropped to the patio, and the kids immediately demanded that I, the doctor, go try to revive the apparently dead bird.  I picked it up, it regained conciousness, and flew away.   The kids showed no surprise.  I tried not to, either.

My patient told me that I’d done the right thing.  A stunned bird righted will generally come to, but if left supine will die.  If your patience wears out before the bird flies, she said, place it upright in a box or other structure that will keep it upright, and most will live to fly.

I hadn’t known that. I asked for, and received permission to put that information in my blog.

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I came to realize that taking call has all the earmarks of an addictive process, and wrote about it in another forum.  Other people, besides doctors, take call.  In the context of symptoms that could be psychological or physiological, I talk to patients about what addictive processes have in common.  This particular patient agreed vigorously.  I printed out my essay and handed it over.

I had call the night before, and it went badly.  I have suffered adverse consequences because of call, and missed time with my family.  Call has made me physically ill.  As the years go on, I spend more and more time recovering from call.

But I keep doing it.

I felt like the biggest hypocrite in northern British Columbia.