Archive for March, 2019

Underworked and overpaid: my 800th post

March 27, 2019

I figured on low patient flow,

At least till the thawing of snow

The warming of spring

The break up will bring

As the snowbirds go to and fro.

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 Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

I anticipated low patient flow, but not this low.  So far in the course of three clinic days I’ve attended three patients, average age 70, two of them male.

I asked for and received permission from a patient to write more about his medical problems than I  have.  After extensive investigation and several therapeutic trials with continued deterioration, he came to see me.

One of the previous physicians on the case thinks a lot like I do, and in his thorough work up I found some of the more esoteric tests I enjoy.

The larger the number of doctors you see before you get to me, the smaller the chance that I’ll have anything constructive to add.  Everything reasonable has been investigated up to now, I said, and anything treatable I find relates more to me thinking unreasonably than it does to deficiencies on the part of the other doctors.  Still I ordered a dozen more blood tests, added three new items to the problem list, and recommended a lot of lifestyle modification.  Which, as always, came down to 8 things: nicotine, caffeine, alcohol, diet, exercise, sleep, seatbelts, and marijuana.

I had to explain that my tenure here is very time limited and that further follow-up would be elsewhere.  We discussed the relative merits of the Mayo Clinic and the VA.

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The sun shone brightly today.  The snow, pushed to the edges of the parking lots to form glacier seedlings, is melting steadily, keeping the heat from the days.

Back when rivers served as highways in Alaska, dogs hauled freight on ice, but boats could move more goods faster.  Thus the spring thaw assumed great economic importance during the Gold Rush, which brought non-Natives here in large numbers for the first time.  Alaskans call this season “break up.”

We have had enough trips to Alaska that we can talk about the long Arctic summer day and the weeks of the Arctic night.  We recall when we landed in the rain and flew out after the ocean froze.  But this is the first time we’ve been here for break up.

While fishing on Sunday we noted large floating white chunks, ice come down the rivers and into the sea with the snow melt, along with trees and other debris.

Break up also brings the snowbirds back from the lower 48.  Those folks, on average older than those who rode the winter out here, should bring an increase in patient flow.  Until then, I’m overpaid and underworked.  Not many would complain.

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Fishing and electronic medical record systems: one is a waste of bait, the other is a waste of time.

March 20, 2019

The computer is a drag on my brain

I would rather the cold and the rain

While I’m up in this state

It’s more fun to waste bait

Is it really that hard to explain?

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 Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

Bethany and I booked a fishing charter on Sunday. We slept poorly and had the magic moment together of loading the car in the darkness and setting out well before light.

We drove into Homer, immortalized by Tom Beaudette in his literary series as the End of the Road.  It sits on Kachemak Bay, made famous by the TV reality series on Alaska homesteaders.

We shared the charter with a party of 4 from Anchorage: 2 doctors (an OB and the only pediatric orthopedist in the state) and two public defenders.

The morning brought much rain and no nibbles. Bethany and I napped intermittently and the young professionals chatted and waited for fishpole ends to dip, while the captain kept the boat trolling back and forth.

In the afternoon the spell was broken when a doc brought in a very nice salmon, about 10 kilos or 25 pounds.

Pacific salmon spawn once and then die.  The king salmon, also called the chinook, reach the biggest weights and carry the most fat of all the species, even more if you get them in winter, before they make changes for breeding.

The sun came out in the afternoon as we trolled back just off a glacier that sent strong chilly winds.

No one got seasick, and no further salmon showed any interest in the baits.

Perhaps we didn’t catch any salmon, but we saw lots of sea otters, loons, eagles, and a seal.

We went out to eat in Homer at a Mexican restaurant; I showed off my Spanish and told a couple of jokes with the hostess from Guadalajara.  We saw a moose on the way back.

The next morning at orientation, I could still feel the boat rocking.

My computer training started in the afternoon.

I don’t like what computerization of records has done to American medicine: stolen physician time from medicine to data entry.  Few of the quality metrics improve patient care.  New studies are finding examples of patient harms from the electronic medical record.

My experience with this particular system goes back a couple of years, and crosses state lines.  Every update promises improvements and brings functional deterioration.

Such systems hurt the basic functions of health care but aid administration.  Report generation and billing get easier.  Bad systems requiring frequent retraining provide employment.  The government keeps expanding the suite of quality metrics that does not help patients but demands more administration, which now tops the list of American medical system price increases.

I whined for a while.  My trainer didn’t disagree, then I went back to learning.

All in all, if I’m not taking care of patients, I’d rather be fishing.

 

Back in Alaska

March 19, 2019

To come back we both felt the push

To Alaska, this time, not the bush

We see cars, we see trucks,

But never mukluks

You could say that life’s rather cush.

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 Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

 

We have now flown so many times to the 49th State that we managed to arrive at our destination the same day we left.  Still, we traveled for 17 hours.

We got here shortly after the “spring forward” time change, which sends the entire country one time zone east.  We dealt with that problem by going three time zones west.

Coming to Alaska till now has meant “the bush” to me: places accessible only by air or water.  High prices, consistent foot traffic, ATVs and snow machines on the streets at all hours.  Life in those places resembles life on islands, with a close sense of geographic identity and an almost  complete lack of theft.  You don’t need driver’s licenses or license plates if you have a vehicle there.  And most people don’t.

The majority of the patients I’ve cared for in the bush have been, well, Alaska Native.  Specialist care means flying into Anchorage (in one place it meant a boat ride to Ketchikan), with all the implied hazards, not to be undertaken lightly.

And now we find ourselves in a metropolitan area with a couple of movie theaters and a really great selection of grocery stores.  The main thoroughfares have traffic lights (that work).  We haven’t seen a single ATV on the streets yet.

The hospital architecture resembles that of the hospitals of western Iowa where I’ve worked, but the directory here lists dozens of doctors, including at least one surgeon.

It’s still Alaska.  Restaurant prices and portions befit the largest state in the Union.  We found a pile of moose droppings five steps from where we parked the car.  The sidewalks show the ravages of multiple, radical freeze-thaw cycles.  The Walmart parking lot pavement consists mostly of chuck holes.  Ravens dominate the skies, eagles come a close second, and the drone of small aircraft continues throughout daylight hours.  When clouds clear, you can see breath-taking mountains in more than one direction.

A moral dwarf amongst real veterans

March 14, 2019

Technically, you can call me a vet

Though I never faced much of a threat

And now the VA,

Making up for bad pay,

Is paying off Uncle Sam’s debt. 

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 Canada.  Any identifiable patient information has been used with permission.

Bethany and I drove up to the Sioux Falls VA hospital for my annual rheumatology appointment.

I have ankylosing spondylitis, a close cousin of rheumatoid arthritis which primarily affecting the spine.  It hurt me since before I turned 18 until my first injection of Enbrel in 2000.  It kept me out of Viet Nam, but not out of the Public Health Service.

So that I now qualify for Veterans’ Benefits, including health care.  The VA pays for an injectable medication which would retail at over $60,000 per year.  When I need a refill, I make a call and it appears on my doorstep in a Styrofoam insulated box in 2 or 3 days.

By comparison to the price, one 2-hour drive and 4 lab appointments yearly rates as a Best Buy.

Because I hurt for so many decades, by the time the pain stopped my body had gotten really good at generating and recognizing endorphins.  All in all, I feel better than I did when I was 18.

And when I sit in public places, I never stop my physician observations, even when I’m a patient.

I watched and listened to the Real Veterans in the waiting rooms today, and I made diagnoses.  The swollen knuckles of rheumatoid arthritis.  The blotchy facial redness and bags under the eyes of alcoholism.  The bug eyes of hyperthyroidism.  The slowness, shuffle and tremor of Parkinson’s.  Way too many “thousand-yard stares” of PTSD.  The scalp scars, cane, and abnormal gait of a traumatic brain injury.  Too many missing limbs to count.  Behind me, the conversation’s speed and volume (loud enough to hear, too fast to understand) of bipolar mania.  The hopeless faces of depression.   And attentive spouses steering veterans in wheelchairs.

While the lab tech (who gave me permission to write this) drew my blood, I noticed swelling in the front lower part of her neck.  I told her to get her thyroid checked, specifying thyroid stimulating hormone (TSH), and anti-thyroid peroxidase (TPO); and an ultrasound if those tests come up normal.

It doesn’t take much historical knowledge to be able to recognize the conflict that modified the hero.  Although, with two fronts ongoing for the last 25 years, I can’t tell the Iraq vets from their Afghanistan contemporaries.  Some served in both theatres.  Some Korean vets served in Viet Nam.

I don’t feel myself a veteran in the presence of the real ones, I feel a moral dwarf.  I never faced a greater danger than a drunk’s slow punch in the ER.  I put up with bad pay and bad management for 5 years.  I lost income, my fellow beneficiaries lost things that cannot be replaced.

Still, the VA treats me the same as they treat the Real Veterans.  Part of the culture of VA employees involves a lot of caring and warmth that people bring from their hearts but the Federal Government does not pay them for.

For my time in the Public Health Service I got 5 years of cross-cultural experiences that could never be purchased.  And now I get benefits equal in value to a good full-time job.

 

 

Another colleague died

March 11, 2019

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 Canada. Just back from months in northern British Columbia, I have a week at home before my next assignment. 

A colleague died in my absence.

He was never my patient. While I knew much of his case I knew it from rumor and hearsay and other public knowledge, but I do my best not to include identifiable information in this post, understandably short and understandably without a limerick.

Even if I’d written about him before, having to search through 400,000 words would keep that information confidential.

He made decisions I would not have made but for which I cannot fault him; they stand as his own magnum opus. Like most of the docs of our generation, he faced the monstrous paradigm shift away from paper records, and dealt with it by retiring before he burnt out.

As we go through life, the events we attend reflect our phase of development: birthdays followed by graduations followed by weddings followed by retirements followed by reunions followed by funerals.   I have seen the demise of  too many friends and colleagues during this last year, and I do not anticipate that the rate will do anything other than speed up.

Retirement kills a distressing number of doctors; few get to enjoy more than a couple of years.

But the narrative we tell ourselves is that we’re each going to be that one doc who practices and practices well till age 85, then starts to party and dies at age 100 from causes related to partying too hard.

I was away during his last hospitalization, and I won’t be in town for the funeral.

Essentially, I didn’t see him after he retired.

The best life lesson I can take away would be to make time to visit my contemporaries more often.

It’s a life lesson for all of us.

March 10, 2019

I had me a weekend on call

With patients good-looking and tall

As the assignment will end

A free day I’ll spend

And perhaps I’ll return in the fall

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 Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

I had call for this locum assignment’s last weekend. Things started abruptly with three complicated patients already in Emergency.

Over the course of the weekend I hospitalized one patient overnight.

Winter sports generate their fair share of injuries. Despite good protective equipment I took care of hockey players who encountered a basic truth of the universe: two objects cannot occupy the same space at the same time.

I have not seen nor heard of a curling-related injury. That sport has limited following in the US, perhaps because of its lack of violence.

Newton’s 3 laws (a body in motion remains in motion unless acted on by an external force, a body at rest remains at rest unless acted on by an external force, and every action has an equal and opposite reaction) applies to skiers and snowboarders, no matter how good-looking they are.

Canada legalized marijuana less than a year ago. The legal stuff carries high potency, and comes at an affordable price.  I cannot for the life of me figure out why anyone would run the risk of illegal adulterated weed in the face of accessibility of a relatively pure product.  But some people do.

In other places, at other times, I’ve taken care of people who consumed so much alcohol that they lost consciousness during winter snow falls. Brought to the ER, the ambulance crews could estimate the length of time they had been exposed to the cold by the depth of the snow that had accumulated.  Not one of them developed frostbite.

Which does not mean I don’t see an occasional case. The most memorable one came one summer in New Mexico, when the patient, bitten by a rattle snake and ignoring instructions to keep a layer of cloth between skin and ice pack, froze the top layer of skin.

When the sun came up Monday morning I could account for a decent 6 hours of sleep.

The weekend call doctor here gets Monday off. After a leisurely breakfast, I came in about 9:00AM and started working on clearing up administrative odds and ends.

The office manager found me after lunch, hard at work rewriting a referral letter that I’d sent to the wrong specialist, not realizing two had the same distinctive, 4-syllable name.

The government covers rural physicians for 43 days of yearly locum tenens, running from April 1 to March 31. She explained that my Sunday call exhausted that particular account.  Tuesday, this assignment’s last day, could not be paid for.

I grinned.

A day off.

Part of the adventure.