Archive for July, 2019

The value of not judging

July 27, 2019

If your logic is flawed I won’t say

And I’ve found at the end of the day

I do far more good

If I avoid, as I should,

Judging others as I go on my way. 

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.  After two weeks vacation, I’m working now as a hospitalist in Sioux City.

Even when I’m not at work, I’m still a doctor.

On a Saturday walk I passed a workman using a grinder to remove mortar between blocks in a wall.  Covered with dust, he still had a moment to greet me.  In the silence that followed the grinder’s off switch, we chatted, and I wondered how to approach the idea of safety equipment.

After a while, I pulled out one of my hearing aids.  “I used to work construction,” I said as I held it up.

He said, “I’m 55 and I’ve been doing this since I was 17 and it hasn’t killed me yet.”

I didn’t point out the flaws in his reasoning.  I kept chatting amiably.  When I turned to go he said, “Maybe next time you see me I’ll be wearing earplugs and a mask.”

As I walked on I marveled at the effectiveness of motivational interviewing.  By not lecturing him I got him to think about his decisions.

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As a social gathering the same day I met a young man with a pronounced stammer.  When I could, I maneuvered him away from the crowd.  His stammer eased.  I asked if he’d seen The King’s Speech, a movie having to do with UK’s King George VI’s stuttering problem; he had.  I asked if he’d ever tried propranolol.  He hadn’t.

Originally approved by the FDA for high blood pressure, the first of a class of compounds called beta blockers, I learned about it in medical school.  We have better drugs now for the original indication, but, because it blocks some of adrenaline’s actions and it gets into the brain, we have found uses for it in stage fright, performance anxiety, excessive blushing, excessive sweating, migraine, hyperthyroidism, essential tremor, and premature ejaculation.

But it also works for stuttering.

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I had to drive to Minneapolis for the yearly medical exam required to keep me coming back to Canada.  Waiting for my name to be called for lab work, I sat across from a nice-looking but obviously distressed young woman.

With tears streaming from her eyes and her nose running, I formulated a list of possibilities, or differential diagnosis.  After she yawned a couple of times and shook violently for a few seconds, the most likely possibility came down to acute narcotics withdrawal.  I had no wish to intrude on her privacy, and did not look her in the eyes to check for dilated pupils, and I couldn’t confirm goose pimples through her long sleeves.

She is not my patient.  I do not have a Minnesota license.  But I have gotten past the tendency to judge addicts.  I could read her discomfort in her body language.  And I knew that her backstory would be full of drama, irony, and tragedy.

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The start of a new old adventure

July 7, 2019

You know, I said with a smirk

I get along fine with the work

But the record electronic

Is like the old plague bubonic

And did away with the former ward clerk.

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.  After two weeks vacation, I’m working now in Sioux City.

A week ago, I stepped back into one of my home town hospitals as a hospitalist.

The United States and Canada remain the only industrialized countries where outpatient doctors regularly do hospital work, but it didn’t used to be that way.

When my father finished his cardiology fellowship and hung out his shingle, hospitals assigned beds to doctors on the basis of seniority; a new doctor would have to ask for a consult to get a patient admitted.  A hospitalist, that is, a physician providing patient care only in the hospital, would have been ranked with the interns and residents; close to unthinkable at the time.

In the early ‘80s, in residency, we got taught that hospital work justified extending the work day because it represented revenue without overhead.

I found out different in private practice.  Drive time robbed the efficiency, and later, so did architectural changes.  In the hour it took to care for 2 patients at two hospitals, I could have attended 4 at the office.

In those days, we talked about the waste of having six docs see 2 patients each at two hospitals, but we didn’t want to give up continuity of care.

Then one summer, I volunteered to take care of my practice’s hospitalized patients at the facility closest to my house.  My partners moved their clinic start time from 9:00 AM to 8:30 AM, I moved mine to 10:00 AM. By the next summer I was rounding on 18 patients, still able to arrive at clinic on time.

I could move fast because I chose the last hospital in town to adopt the electronic medical record (EMR); I could not have kept up that pace except using paper charts.  My Dictaphone handy in my pocket, I dictated while I walked, with a cart for the charts.  Over the course of time I evolved small efficiencies that added up to hours.

I learned a lot.

Later, during my years with Community Health, the crush of a growing inpatient load necessitated giving over our hospital practice, with the exception of newborns, to the newly established hospitalist programs.

Two trends encouraged primary care physicians to leave hospital work.  When the EMR looks like a stick, a hospitalist program looks like a carrot.  And the larger cultural context serves as a push towards increasing specialization.

Most hospitalists work through hospital programs; few practices designate one of their own as a hospitalist.

(In Prince George, British Columbia, the growing trend of new docs keeping their business 100% outpatient without hospital credentials, has given rise to a growing coverage problem.)

I have a temporary position as a hospitalist in Sioux City, the place of my permanent residence. On my first day I saw a lot of faces light up in recognition, staff and patients who remember me from 5 years ago.

But consider the irony: I’m doing the same job I did 9 years ago, but now all at the hospital.

 

 

A visit from my friend of 50 years

July 2, 2019

My friend, on a trip down the road

Made a stop at my humble abode

He’s met the requirement

For his retirement

And there’s wisdom that he has showed.

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 just finished two weeks vacation.

 

My friend of 50 years, Al Willard, came to visit.

Al and I met freshman year at Yale, and our friendship cemented the summer of 1970.  We shared a house Junior and Senior year.  One Sunday we rode our bicycles the 50 miles from New Haven to New London to visit the Connecticut College for Women.

We planned a bicycle road trip from Connecticut to Colorado after we graduated.    In the process of readying the machines we ignored the news and the weather reports, and pedaled right into the wrath of Hurricane Agnes.

Most of the country remembers that summer for Spassky-Fischer chess and Nixon’s Watergate scandal.

We started badly prepared and (by today’s standards) ill-equipped.  By the time we finished we had learned a good deal about bicycle repair, camping, and friendship.

In 6 weeks of road trip we pedaled 20 days and covered 2100 miles.  That relatively brief window assumed a disproportionately large position in making us who we are.

Three years later, the summer before med school, I completed my coast-to-coast ride when I pedaled a different bicycle out to San Diego to hang out with Al, working on his PhD.

(The same summer, Bethany visited her friends on the 3rd floor of the same building where Al worked on the 4th floor; we would not meet till 1979.)

Over the next ten years I built my medical skill set while Al went from PhD to post-doctoral research to researcher.  We have continued to visit each other every few years.

Two years ago he retired from his last job, the deputy director of National Institute Neurologic Disease and Stroke, with more than a thousand employees and a budget in the billions.

He loves his retirement.  He gets a lot of exercise, he does a lot of brain-intensive games.

He still has his mother and they’re working on her bucket list.  They’ve done New Zealand and Australia.  This summer they’re going to the Calgary Stampede, it will be their literal first rodeo. He helped move her to his sister’s place, empty out the old house, and establish her in the new.  He visits his siblings and his nieces and nephews.

I scheduled nothing during his visit, but the cherry crop came ripe just before he arrived, and we picked, pitted, and jammed.  Bethany made a couple of pies.

I cooked a batch of mole (mo-lay), a spicy Mexican dish with chocolate, tomatoes and chicken.  I honed that recipe during the two years we shared a house.  It brought back memories.

But at the last minute my next gig requested two hours of orientation for the final night of Al’s visit.  I resented it, but I went anyway.

I still have a lot to learn about setting priorities, and even more about retirement.