Archive for June, 2019

A wedding in Indiana

June 25, 2019

Here’s to Alfred and to Nicole

Their plan, their life and their goal

Two doctors, a pair

To their joy, is our prayer

It comes from the heart and the soul

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  I plan to take a few weeks’ vacation

Bethany and I have known the Benzonis, both physicians, for decades. Tom staffed ER at one of the hospitals, and we established a good working relationship early on.  Noreen ran a Community Health Center.  Our children played together.

During the winter their daughter, Nicole, asked if I would officiate at her upcoming wedding.

My initial reaction mixed equal parts of honored and surprised.  I come from a Jewish background, the Benzonis Catholic, and the groom, Alfred, Buddhist.

I agreed immediately.

A healthy exchange of emails followed.

I got an online clergy certificate, good for weddings in all states except Pennsylvania and Virginia

Wisdom is where you find it.  Buddhism gave me the best wedding vows.  Jewish nuptial traditions lend a basis for stability, and for great showmanship.

The following comprises most of the wedding, and appears here with the permission of the family.

The heart of any wedding is an agreement, an understanding, or, if you will, a contract between two people.  That contract may be verbal or written, it may be implicit or explicit, it may be according to traditional formulae or it could be composed on the spot.

Change is inevitable.  You cannot cross the same river twice.  You are not the same person you today that were went you went to sleep last night.

Nothing can be understood outside of its context, and the context of the human race is changing faster than it ever has with no signs of slowing.

How, then can two people who will change inside a context of radical change, pledge permanence?

In the face of all cynicism and aridity of the soul, love is as perennial as the grass, a force of the universe as strong as gravity, so powerful that it can bring order out of chaos.

Ketubah is Hebrew for contract, and that contract, that you’ve already signed, is the heart of your wedding.  It seems a good idea then, that any contract should be regularly revisited, and, if need be, revised.  What does this marriage mean to each of you?

Strongly consider renewing or renegotiating the contract on your anniversary, whether it involves something as prosaic as bathtub drains or something as profound as children.  The contract can be as flexible or as rigid as you make it.  But stick to your agreement for its term.  Don’t change the rules except by mutual agreement.  Be forthright in communicating your needs and expectations. Be good to each other; given the choice between doing something nice and something else, choose nice.  Be generous to each other, both giving and receiving.  And be forgiving, for yourself and your partner.

Nicole and Alfred do you pledge to help each other to develop your hearts and minds, cultivating compassion, generosity, ethics, patience, enthusiasm, concentration and wisdom as you age and undergo the various ups and downs of life and to transform them into the path of love, compassion, joy and equanimity?

Alfred and Nicole: “We do.”

Recognizing that the external conditions in life will not always be smooth and that internally your own minds and emotions will sometimes get stuck in negativity, do you pledge to see all these circumstances as a challenge to help you grow, to open your hearts, to accept yourselves, and each other; and to generate compassion for others who are suffering?

Alfred and Nicole: “We do.”

Understanding that just as we are a mystery to ourselves, each other person is also a mystery to us, do you pledge to seek to understand yourselves, each other, and all living beings, to examine your own minds continually and to regard all the mysteries of life with curiosity and joy?

Alfred and Nicole: “We do.”

 Do you pledge to preserve and enrich your affection for each other, and to share it with all beings? To take the loving feelings you have for one another and your vision of each other’s potential and inner beauty as an example and rather than spiraling inwards and becoming self-absorbed, to radiate this love outwards to all beings?

Alfred and Nicole: “We do.”

 

 

 

Bringing Alaska fish to the 500-year flood

June 17, 2019

We flew back to the corn belt

All the way the worry I felt

I’d hoped, I had chosen

To keep the fish frozen

But feared the hundred-pound melt. 

 

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  I plan to take a few weeks vacation

At this time of year, close to the summer solstice, Alaska nights never get really dark.  We left Friday morning in the semi-darkness, and drove to the Kenai airport.  We saw one caribou and no moose on the way.

The day before we’d brought frozen halibut and salmon to one of the many fish processors for packaging with dry ice.  We put most of the fish into 50-pound boxes, and arranged to ship the remainder, about 36 pounds, to our friend Les, in Anchorage, who took us out halibut fishing: https://walkaboutdoc.wordpress.com/2019/06/08/the-biggest-fish-i-caught/

I worried about the fish.  I have had enough summer travel plans drowned by thunderstorms and delayed flights, occasionally arriving 2 or 3 days late.

When we finished having our bags weighed, I identified myself as a physician to one of the ticket counter staff and advised her to get her thyroid checked.  She replied she already knew she had a problem and she intended to restart her medication.

By the time we walked out onto the tarmac the light had brightened enough to show colors.

We go out of our way to sleep poorly the night before a long plane trip so that we sleep on the plane.

The frozen fish stayed at the back of my mind, through Kenai, Anchorage, Seattle, Portland, Omaha, and into Sioux City.

But the worry didn’t keep me from sleeping, as per plan, on the plane.  Somewhere over the Rockies, flying into the night, the sun went down.

Our friend, John, picked us up.  We loaded the luggage and the two pieces with fish into the trunk.

The darkness of the Nebraska night, something we haven’t seen in months, came as a relief to our eyes.

Much of the Midwest has seen record flooding.  When I came back from my first locum tenens trip, in 2010, I found the Interstate closed in Omaha, with Sioux City onramps repurposed as boat ramps.  They called it the 500-year flood.

Now, less than a decade later, we have another 500-year flood. John navigated through the blessed darkness, detouring around closed Interstate highway.  We chatted about our mutual adventures while Bethany sleeps in the back seat.

Finally at home, with the coolers in the basement, I cut through the tape to find the fish still solid frozen.  We dumped it into the freezer, filling it to the gunwales.

We would not have had room for the 36 pounds of fish we sent to Les.

Unsustainability ends in warm poignance.

June 9, 2019

 

In 12 weeks, I saw 53.

I thought, what a great place to be

But who’s keeping score

When you establish rapport

And on weekends, head out to sea

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.

Thursday dawned with one patient on the schedule.

In the last 12 weeks I performed a total of 53 outpatient visits.  My busiest day had 6 patients; I had 6 days with no patients at all.

In contrast, while in private practice, the day after Thanksgiving 1994 I saw 63 patients.  (If you must know, strep throat and flu, with one patient having an active heart attack.)

I never spent less than 30 minutes per patient, a few went close to 2 hours.  Ages ranged from 54 to 90.

Few doctors in Alaska’s population centers accept Medicare because the payment schedule doesn’t cover the added expense of dealing with a truculent bureaucracy.  Thus, aside from veterans, the aged have difficulty accessing medical care.  This, the final visit of my assignment, means that the problem has worsened.

Today’s patient came in at 10:00 AM.  Mostly we talked about his medical problems.  Thus I had to ask his agenda.  What do you want to be doing in 5 years?

The patient’s agenda always trumps the doctor’s agenda.   For example, the exercise program won’t work if the patient hates it, and those who love smoking won’t quit.

My patient and I come from the same generation.  We both love fishing and know exercise’s value..  Both love our chosen professions. We both face the inevitable physical need to slow down, and we both wonder what we’ll do with our time without a schedule.

While I want to keep going at least another 16 years, he wants to be done in 5.  He’s already starting to dismantle his infrastructure.

In the end, the 90 minutes I spent with him revealed things needing investigation.  I put orders into the computer, and refilled prescriptions.

But it also gave me time to establish rapport.  By visit wrap up, we found our agendas closer than we’d realized.

I recommended a doc in a close (by Alaska standards) town with whom I worked at one time.

At the end, our handshake held warmth; under other circumstances our friendship would have grown.  It also had the same poignance of finality that has permeated this assignment.

+-+-+-

Low patient flow lacks sustainability.  It doesn’t generate enough income, and inevitably popularity will grow or wane.

But at least 4 alcoholics decided to change, including one past the age of 70, which I’d previously regarded as sobriety’s event horizon.

If I hadn’t had so much face time, I would have missed the basic problem for at least 12 patients.

Five people needed their thyroid doses changed.  I ran a lot of tests that brought reassurance but did not change management. I made one great diagnostic coup.

At least half my patients work or have worked in fishing.  Showing fishing photos on my phone strengthened rapport.

I used my Spanish 4 times.  I exhausted my Japanese, Korean, and Tagalog vocabularies.

Bethany and I had a wonderful time fishing on the weekends.

I walked out the door at 4:00 PM to clear, blue sky, bright sunshine, billowing white clouds and a perfect temp of 18 C (63 F).

I had no celebratory good-bye lunch; no thank-you cards circulated.

But I hadn’t expected any.  I did my job well: I closed down the practice.

 

 

The biggest fish I caught

June 8, 2019

For halibut you use a large bait,

The reward? A fish of large weight

At the end of the line,

The object’s to dine

But you might need a very large plate.

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 met Les in residency in Wyoming in 1981.  We have been friends since.  After training, he moved to Anchorage.  We reconnected in 2010 when I worked in Barrow.

He arranged for us to fall into the dream Alaska fishing trip of a lifetime.  For a week, we’d wake up, catch our limit of silver salmon, then halibut, followed by lunch.  We found out we love fishing.

Last weekend Bethany and I went fishing again with Les, who towed his boat to Seward.

We arrived when the tourist season that sustains Seward started to blossom.  Tents and RVs of every size filled a dozen campgrounds.  Visitors to the Sea Life Center packed the parking lots.  Traffic along the waterfront crawled.

We visited Seward back in 2010, taking the train from Anchorage with no other thought than tourism.  We saw glaciers, visited the Sea Life Center, and laughed when a sea otter scrambled across the parking lot.

This time, though, we booked a bed and breakfast and we had fishing on the agenda.

A brooding beauty started the day, low dark clouds brushing up against snow-covered peaks.  We crept out of the harbor to speed into Resurrection Bay.

The morning passed futilely trolling for salmon.  In the late morning we shifted locations.

One of Les’s patients, a fishing charter captain, had clued Les to a halibut spot.  (No, I’m not going to divulge the location of this honey hole. Are you kidding?)

We dropped our lines into 200 feet of water, about an hour before the slack at high tide, when the water stops moving and the halibut like to feed.  Les rigged t-shaped leaders with two circular halibut hooks, and a 4-pound weight (unaffectionately called a cannon ball) and baits of herring and squid.

I felt my weight hit bottom, then cranked my reel a dozen times to cut down on by-catch of rock fish.

From the beginning I got a lot of activity, the end of my rod jiggling at intervals, over the course of 15 minutes.  Then nothing.

I cranked my rig up and found the bait gone.  With fresh bait I dropped the ball to the bottom again.

Less activity this time, fewer nibbles for all.  Les slipped his rod into a socket in the gunwale and went for a nap.  My rod went into a socket, too, and I found a way to sit down and face Bethany on the starboard side of the fishing deck, while keeping my hand on the rod, vigilant for thumps.

After about 20 minutes of mild action followed by 10 minutes of none, I cranked the hooks up again to find the bait gone.  I slipped chunks of herring and squid onto the hooks, took the drag off, and let the cannon ball hit bottom  This time, out of sheer perversity, I cranked the reel 13 times and sat down.

The rod tip moved, I let out a bit of line.  More jiggling, more line out.  Then the pole moved violently and consistently, and I started working the reel, telling Bethany, “He’s committed.”

A 4-pound cannon ball comes to the surface reluctantly enough, but a fish who wants to live actively fights.  When cranking didn’t do any good, I stopped till the fish let up fighting, then cranked some more.  Bit by bit, the fish arose from the deep.

My left hand fatigued, and I slipped the rod butt back into the socket.  After a while I had Bethany hold the rod while I reeled with my right hand.  Then I had her reel for a while.

When she fatigued I took the pole back.  For quite a while I cranked, and watched a bit of seaweed crawl up the line to the tip, and slide back down.  I remarked I didn’t think I was making progress.  Bethany looked at the reel and verified slow advancement.

We woke Les, and we all took turns cranking.

Finally a very large shadow showed 10 feet down, and Les went for the shotgun.

If you go after halibut you should go armed.  Les loaded his a single-shot, break-action, short-barreled .410 with 7 ½ bird shot.  I brought the fish alongside, placed my noise-cancelling muffs and stood back, clinging to the pole as the fish struggled.

A splash of water and a loud bang signaled the end of the fish’s life.  Les gaffed him and hauled him out of the water.

I have never caught a fish even close to 62 inches long and 92 pounds, and Les declared no larger fish has every been hauled onto his boat.

The halibut exceeded the length of the well by two feet; Les suspended him from an eyebolt, and constructed a block and tackle from cordage.  To keep the swinging fish from hurting us, he made the tail fast to the deck.

halibut 2019 Seward

Then we went back to fishing.

Bethany brought in a 45 lb halibut that would barely fit in the well, Les brought in a 50-pounder that would fit only with folding.  Bethany caught a benthic rock fish of good size.  When I brought in another, we decided we had enough fish for not one but two days.  Les brought us back to Seward.

Mostly we like to process fish on our own as much for a bonding experience and a time to relive the trip as to save money.  But with close to 150 pounds of fish, Bethany and I decided to pay to have our two fish filleted, vacuum packed, frozen, boxed and shipped.  We gave our rock fish to Les.

With the boat hauled out, we turned our exhausted attention to dinner.  We in fact found a place that avoids the tourist hordes by falsely advertising “Cheap Beer & Lousy Food.”

2019 June cheap beer & lousy food

Another assignment draws to a close

June 5, 2019

There are beginners, and then there are purists

There are locals, and then there are tourists

The notes that I penned

As this job comes to an end

For a doctor, a healer, a curist.

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.

When I walked in Monday morning, I had one patient on my schedule for this, the final week of the assignment.

I knew when I said ‘yes’ to the gig that I’d start with slow patient flow that would diminish towards the end.  On the basis of anticipated small demand, I could negotiate a 4-day work week.

On my busiest day I took care of 6 people.  Altogether since March 17 I’ve taken care of 50 patients.  I have had exactly one busy afternoon, and 6 days that finished with no direct patient contact.

My schedule stands empty for the rest of the week, a sign that I have done my job to help this practice make a transition.

During the day I do a lot of medical reading, checking my IN box every 20 minutes.  I with a dozen or so prescription requests, lab results, and phone calls a day.

But the Kenai peninsula has awakened from the winter hibernation.  Outside the sun shines clear.  Looking south in the distance you can see the billowing white clouds over the sea around Homer.

At the clinic we share videos of mother moose with twin calves wading in the shallows; when we see moose in town we make sure to give them a wide berth.

The salmon have started to run up the rivers, and with the salmon come the fisherpeople, with RVs and boats and camper shells and tents.  They come with light fly rods and dip nets.  Soon the shallows of the Kenai, Kasilof, Russian, and Anchor rivers will be lined with anglers shoulder-to-shoulder in the annual spectacle referred to by locals and tourists alike as “combat fishing.”

Traffic has snarled.  Bethany went to a bakery and found a line snaking out the door.  We went to a large grocery with a wonderful selection and found crowded aisles and long check-out lines staffed with seasonal help.

For the first time since we arrived in March, this week I don’t need a jacket on my way to work.  The mosquitoes, suddenly hatched and warmed from their cold weather torpor, enjoy my exposed skin.

Bethany and I talk garden plans, and the friends we miss.  We wonder aloud about the stacks of mail, and we look forward to sleeping in our own bed.

This part of the adventure will have lasted 12 weeks, which we’ve found is the longest we want to be gone.

We’ve started to pack, we’re making arrangements to bring the fish back on the plane.

It’s time to go home.