The Summer in Review

The months I spent here were 4

And I thought as I walked out the door

Of the esprit we displayed

And the tractor parade

And how I might come back later for more.

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, my 50^th High School reunion, I just finished a 4-month assignment in northwest Iowa.  Any identifiable patient information has been included with permission

I spent the last 4 months in Iowa farm country. Agriculture dominates the town’s economy.  The local subculture has biases against tobacco, alcohol, drugs, and infidelity, and for hard physical work with personal integrity.  Thus my patient population included a lot of very spry folk in their 70s, 80s, and 90s.

I attended several in those age groups with Workman’s Compensation injuries.

I identified Parkinson’s disease in more than a dozen patients, and over the course of the summer saw them improve as I gradually increased their doses of carbidopa/levodopa (trade name, Sinemet).

Four different patients presented with various symptoms which turned out to be hypothyroidism. Some I made better.  But I left before the mandatory six week wait for hypothyroid follow up.

I suspect vitamin B12 deficiency in anyone with neurologic problems. Five such patients had low B12 levels.  Several had borderline levels, and when I did the confirmatory tests of methylmalonic acid and homocysteine I found disease that needed treatment.

I approached several cases of heart failure with the relatively new combination of ACE inhibitor and beta blocker.

Nobody made an inappropriate request for a scheduled drug, a tribute to the tiny medical community and the doc who preceded me.

A number of patients came in with confusing, dramatic neurologic symptoms looking like stroke but resolving when treated for infection and dehydration.

The hospital CEO, a nurse by training, has great leadership skills and no fear of getting her hands dirty. She did a fantastic job with difficult IV starts. When a staffer fell ill unexpectedly, she cooked and served supper to the inpatients.

Such leadership quality echoes throughout the organization. The clinic manager keeps the staff pulling the wagon in the right direction.  People work hard here. Lab and x-ray results came back with dizzying speed.

I used the electronic medical record to retrieve data, but I dictated my hospital, clinic, and ER notes. I entered my inpatient orders on paper.  My outpatient nurses entered prescription, lab, and x-ray orders for me.  All in all, I got to concentrate on patient care and not on the computer.  In fact, policy keeps computers out of exam rooms.

Early in the summer, a nurse, the clinic manager and I went on a house call. As we left town on the country road, we pulled up in back of a slow-moving MRI semi.  Eventually, he passed a farmer on his tractor, who turned out to be part of a tractor parade that stretched as far as the eye could see down the road.

It slowed us, but we all enjoyed the experience and talked about it for the rest of the summer.

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Another going away lunch

The problem the town now must face

Is to get a doc to replace

My predecessor and me

But I think we agree

That for change, like a storm, we must brace.

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, my 50^th High School reunion, I just finished an assignment in northwest Iowa.  Any identifiable patient information has been included with permission

I have ankylosing spondylitis, an auto-immune disease related to rheumatoid arthritis but hitting the spine harder than the limb joints.

The first patient of my last clinic day has a closely-related disease, and gave permission to write more than I have. He talked about his joint pains,  reminding me how I felt during my many bad days and worse nights with morning stiffness, sleep disturbance and skin problems.  We agreed on specialist referral.

Follow-ups dominated the morning, with a lot of fallout from the recent flooding.

At noon Bethany and I went to the hospital for my going-away lunch, cooked nicely by a nurse brought in from retirement by the dietician’s sudden illness. We chatted over grilled chicken breasts, Asian salad, and apple pie.

My predecessor gave decades of high-quality medical care. Despite much pressure to stay as his replacement, I point out my age.  The town really needs a younger permanent doc.

In the afternoon I strode back and forth between the clinic, with a swelling patient roster, and the ER’s frightening variety of serious illness. With every transition I got 9 steps outside, in the fall sunshine with a brisk cool breeze.

At one point 4 people stacked the CT queue, looking for, variously, blood clots in the lung, skull fracture, brain damage, or appendicitis.

All the scans came back normal.

The day’s final frenzy finished, and documentation’s slow-receding tide left two patients with IVs running. As the sun set I stepped over to the doctor’s quarters, and Bethany and I went out for pizza.  Off and on till after 10:00 PM I went back and forth to the hospital, till the patients hydrated and improved adequately for discharge.

Law enforcement brought a patient, as it turned out, my last patient of the assignment. Trained in medicine and not law, I don’t need to know about the conflict of my patient with society, I just work on fixing medical problems.

Up early, Bethany and I breakfasted at the gas station café. While she packed the car, I came back to sign off dictations and results from the previous day.

We left town later than planned. The fields I passed in June with the barest fringe of green against the brown of the soil, now stood with dead foliage, yielding to the harvest.

 

No man is an island. But a town might be.

There is no testing

When you look and you see there’s a flow
Of water cross the road you should know
And ask yourself why
Cross that flow you would try
To drive, and not another way go.

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 50^th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission

 

After a 5 day weekend I headed back to work in a driving rain, leaving early enough to arrive on time despite slowing for wet roads.

The summer has waned. In June I left home more than an hour after sunrise.  Today, I rolled down my driveway under a canopy of jet black wet felt.

Off on a county road I crested a hill and could see water flowing across the road at the bottom. I turned around at the barricade.

GPS and cell phone navigation apps can’t possibly advise on a problem related northwest Iowa’s rolling hills’ wet spots.   So I called my office manager, who grew up here watching flood waters rise and recede.

I used her directions and a dated paper map. I pulled into the hospital parking lot 30 minutes behind schedule to find I had an unscheduled patient ready and a flash flood warning on my phone.

Within 30 seconds of starting the interview I knew the most likely diagnosis justifying the patient’s early, unannounced arrival. With the glorious speed of a small facility, I had the lab and CT back in less than 40 minutes.  By that time, the problem had progressed in the right direction and I could see the patient’s improvement.

I like helping patients, but I like it more when they get better on their own.

I had a full morning, caring for 8 patients, and clearing paperwork accumulated in my absence.

The weather kept some staffers home, others took their lives in their hands driving through flowing waters.

At day’s end I had attended 4 different people with flooded basements. None had insurance to cover the damage.

My office manager, who had given me such wonderful directions, could not remember when the rain had fallen so hard. For a short time, the town qualified as an island.

After clinic, I drove out to a nursing home. I evaluated the patient, gathering information I could not possibly have gotten without physical presence.

I glanced out the window at torrents of rain while I listened for telltale heart sounds with my stethoscope. I accelerated the pace of the visit because the trip back had two low spots where the road could flood, and I had a responsibility to cover the ER.

I got back OK.

Telemedicine is lower-quality medicine. But in bad weather it’s safer for the doc.  And it’s probably inevitable.

 

And sometimes, it’s about me

It shouldn’t be all about me

It’s about the people I see.

And the good that I do

The what for the who,

And occasionally, a day that is free.

 

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 50^th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission

I did nursing home rounds on Thursday.   Patients come to long term care facilities because of long-term problems.  In the absence of cure, the medical profession settles for treatment.  Thus, in general, I find patients don’t have much in the way of future plans there.

My general approach to smoking relies on hope. I ask, “Do you want to still be smoking in 5 years?”  Most smokers say ‘no’.  Nursing home smokers usually shake their heads, grin sheepishly, and say that they hope they live that long.

This particular facility’s specialty caters to a population that develops incurable diseases at a younger age than the general population. Still, I cared for 9 patients.  I had the pleasant surprise of seeing improvement in 6 and being able to trim the med list of 2.

When I started morning rounds my afternoon schedule had 3 patients; when I got back from the nursing home at 11:45AM I had 4. I rather enjoyed the fact that I could squeeze in 5 more unscheduled patients after lunch.

For the second time since I started here in June, I had documentation and other tasks that kept me working till 6:10PM, a far cry from my usual routine 9 years ago. At that time I started at 7:30AM, sprinted till 5:00 or 6:00, and faced an hour or two of documentation after supper.

Between the nursing home and the clinic, I saw 3 improving Parkinson’s patients.

I had one evening call that involved law enforcement. It went well.

Friday morning I came into clinic and signed in to the computer system. I reviewed labs and answered questions until one of the nurses pointed out that my name didn’t appear on the schedule, and I had no patients for the day.

Five minutes later I had the choice of staying with no scheduled patients or taking the day off.

With so much leisure I drove without exceeding the speed limit, between corn fields turning brown and soybean fields mottling from green to yellow, reflecting on my clinic day.

I felt great. I had seen patient improvement, and had fixed the bleeding and the broken.

Yet my work shouldn’t be about me, it should be about the patients, but confidentiality limits what I can write about them.

Still, my day off was about me.

 

 

 

Bad Call Night, a House Call, a Doctor’s Moment

A change in the dose might be small

But to keep myself on the ball

It’s not about me

It’s rewarding, you see

Going out 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 50^th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission.

Last night I had the only really bad call night so far this assignment, not bad for a gig that started in June. Called to the ER just after brushing my teeth at 10:30PM, I stayed till after midnight.  I can’t give the details of the case that brought me in at 2:30AM, except to say that a very sick patient needed more resources than we have after hours, and left at 3:30AM with follow ups scheduled along with my exhortation to read Beryl Markham’s West With the Night.

Sleep deprivation hits me harder than it did 30 years ago. I try not to show fatigue around patients and staff, but I felt my steps dragging when I started this morning.

I prioritize ER patients when on call, even when scheduled to simultaneously make nursing home rounds. This morning the inherent conflict resulted in my delayed arrival at a nearby Long Term Care Facility (LTCF).  About half the patients didn’t note my tardiness to a place where one can so easily lose track of time.

When I finished long-term patient care early, I begged the nurse to leave me alone in the exam room for a power nap. Elbows on desk, head propped on my hands, I hit REM sleep in less than a minute and awoke 6 minutes later feeling better.  Not well, but certain I could make the 8 mile drive without falling asleep.

Another true emergency dominated the lunch hour as the afternoon schedule swelled from 3 patients to 8. I bolted lunch and squeezed in another 4 minute nap.  I started into afternoon clinic on time but feeling my years.

At 2:00PM I left with nurses for a house call, and fell asleep on the 5 minute drive.

The first house call to this patient found little hope, the second progress. This time the trip rewarded me with a physician’s moment, the gratification of seeing the effects of improved human health and function rippling through the family in front of my eyes.

Back at the clinic, I stepped out of the car with a bounce in my step I didn’t have before I left. I faced a packed afternoon schedule, behind on documentation and still a bit hungry, but full of energy and the joy of having the best job in the world.

 

Physician, anthropologist, and bike mechanic

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 50^th 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 21^st 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

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 50^th 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

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 50^th 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.

Hot job, hot office

In my office I might take a seat

Depending on the degree of the heat

I’ll tell you, no fooling

I don’t get the cooling

And it’s hot enough to cook meat

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 50^th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Summer in Iowa brings sun, heat and humidity. The closer the temp gets to 85 degrees, the faster the corn grows; 2 degrees higher and the growth stops.  If the night fails to dip below 85 degrees the corn loses energy trying to keep cool.

You can find old farmsteads by their wood lots, 1-2 acre stands of trees that shaded a house from the sun in the summer, blocked the wind and snow in the winter, and provided fuel close to home.

Towering shade trees don’t fit in with 21^st century American hospitals’ parking lots and helipads.  Air conditioning provides the necessary climate control.

(Last century, when I visited Cuba, I found hospitals, that depended on open architecture, breezeways, ventilation, and shade trees. But for obvious reasons, they don’t need parking lots.  And I visited in February.)

My clinic office has a great location on the west side of the building. Of all the rooms in the outpatient department, mine alone has no air conditioning.  More accurately, it has air conditioning but it doesn’t work.  On a good, hot, muggy day, I get some cool air in from the corridor in the morning, but as the afternoon wears on, my outside wall takes a beating from the sun, heats up, and radiates into the room.  And as the corn grows, I start to sweat.

Fans help by evaporative cooling. I got an aging tower fan that doesn’t work nearly as well as the desk fan Bethany bought at a hardware store on the square.  If I sit at my desk, the breeze on my face helps.  If anyone seeks to have a conversation with me after 3:00PM, I have to turn the fan so that they don’t suffer too much.  But then, I do.

When I worked in Barrow (now Utqiavik) in the winter of 2011, the hospital hadn’t had the heating updated since construction in 1964. Though the outside temp ran to -40, the clinic area stayed oven hot.  Entering a room, I opened by saying , “You can have privacy or you can have ventilation, but you can’t have both.  Door open or closed?”  And the patients always wanted the door open.  I could  stand by the window that no one ever closed, or I could even go outside without a coat.  Environmental services assured me they could not fix the system.  At the time, with the new hospital under construction, they weren’t about to try.

In New Mexico, my humble clinic’s windows always worked but the electricity didn’t. If the power went off, we opened the windows.  If the power went off in the winter, we kept on our coats.

The patient care here takes place in very comfortable surroundings, but I do my dictations and paperwork in the high 80’s.

Not surprisingly, I find myself spending more time with the patients, and trying to spend less time in my office.

Once a patient, always a patient

The story came as a surprise,

Perfidy, adultery, and lies.

Misuse of narcotics

And antibiotics.

And names I wouldn’t surmise.

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 50^th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I don’t have to know everything in the business; I have to know when I don’t know. I usually know who knows more than I do.

At my graduation from medical school, the speaker (so effective I still remember large portions of the address) told us to look in the mirror every morning and say, “I don’t know.” It took a few years but I got good at it.  Admitting ignorance does not bruise my medical ego anymore because reality has humbled me so often I don’t have one left.

Halfway through a laceration repair yesterday, I realized the wound went much deeper than I thought. I stopped immediately, doffed my surgical gloves, and called for help.

I put the call through a hospital operator who asked me to spell my name, which I did. Then I commented that she knew me but I hadn’t been around for a few years.  I could hear the smile spring back to her voice.

I had to re-introduce myself to the consultant, and, again, the telephone connection could not interfere with the smile.

Earlier in the day I needed to talk to a cardiologist regarding the proper time frame for a referral. I ran into that on-call doc at a dinner conference the week before.  He, too, smiled.

Still, medical communities qualify as living things: doctors come and doctors go. Change is inevitable.  I had a conversation this last week with a member of the Iowa Board of Medicine, and got access to some really juicy stories.  I cannot give the details here but I can give the moral lessons:  doctors should not have sexual relations with patients (and, once a patient, always a patient), they should not write narcotics prescriptions if they intend to use the narcotics for themselves, they should not misuse their position of power for financial gain.

None of those stories related to the local physicians, though some related to changes in the Sioux City medical community. Most came as complete surprises.

Most, but not all.