Archive for the ‘Being a doctor’ Category

A fast 3 weeks vacation

February 14, 2019

In Denver we sat down for a meal,

To talk of how people heal.

We were shooting the breeze

Speaking medicalese

It’s just our typical spiel.

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 took three weeks’ vacation between assignments.

Three weeks’ vacation went fast. We had enough time for laundry and almost enough time for mail before we visited our (physician) daughter, her (physician) husband and their two children in Texas.  Not surprisingly, dinner conversation included medical topics as common as B12 deficiency and as esoteric as clivochordoma (a ridiculously rare sort of brain tumor).  But we also talked about normal stuff like the grandchildren developing, the political situation, physician career development (for all 3 of us doctors) and the progress of my Texas medical license , which I started back in May.

Some states make licensing easier than others, and I wondered out loud who oversees licensing authorities to make sure they act in the State’s best interests.

Bethany and I stayed 2 days with the 2 grandchildren (who between them don’t have 4 calendar years) listening to the pounding of the Galveston surf and watching squadrons of pelicans fishing in knee-deep water.

We flew directly from Houston to Denver. Our youngest daughter and her husband came to Colorado to touch base with family and friends before a planned move to Israel.  Three of my 6 sib, along with spouses and children, live in Denver.

We met in a Persian restaurant for supper.

Medicine has warped our conversations and vocabularies, starting with our internist/cardiologist/Emergency physician father who dropped the words “myocardial infarction” (heart attack) at least six times a meal.

When I had young children, and even after, I literally brought my work home with me, sometimes attending patients in the basement and usually dictating office notes after supper. When I had call, I took the kids with me to the hospital starting, before the first one could walk to when the youngest one hit puberty.  Of course family meals included discussions of the drama and irony my work.

Our youngest daughter married the youngest son of my former medical partner. One of my Denver sisters, an interpreter for the deaf, has been through veterinary school 3 times, and she does a lot of ER interpreting.  Her son, just done with premed, is in the process of studying for the MCAT (Medical College Aptitude Test).  My Denver brother, a paramedic for decades, will apply to PA school within the year.

My other Denver sister has a PhD, arguably the more normal sort of doctor.

The family’s way-off-the-wall sense of humor dominated the evening. At the end of the meal we had a short hands-on colloquium on OMT, or, in common English, back cracking.

 

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Saxophone and life lessons

February 3, 2019

In Memoriam

Diane G.

March 28, 1960- January 24, 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 northern British Columbia. Just back from my 4th Canadian assignment, I’m taking some time off in the States

After a miraculous, 15 year fight with cancer, Diane, my friend and saxophone teacher, died last week. I was with her when she passed, not as her physician but as her friend.  Bethany was there as a friend as well, and to support me.

She died surrounded by the love of her friends and her family.

Diane had to see other physicians while I went locum tenens, but I never found another music teacher. Thursdays when in town meant life lessons along with music.  She would not accept money, so I brought chicken soup.

At her urging, and with her permission, I wrote about her in 2011. I have included the post word-for-word below.

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog.

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant.

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her.

“Well,” I said, “Just lay back on the exam table while I check your tummy.”

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart.

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.

 

 

 

Confronting a smoker with a heart attack

January 13, 2019

 

When it comes to attacks of the heart

Please listen, you docs who are smart

Whenever the bloke

Steps out for a smoke

Don’t yell, and keep your words smart.

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.

Though the patient gave me permission to write about him, I won’t say when this incident happened.

He came in with chest pain. As per protocol, I did the electrocardiogram which strongly resembled previous tracings.  But I also asked for and obtained a blood test for troponin, which rises only when heart muscle has sustained damage.  It came back normal.

But we have learned that sometimes the damage doesn’t show up on the initial blood work, so I ordered the same tests 4 hours later.

I read the second ECG with alarm: a sag in the line connecting the wave representing the heart’s contraction, with the deflection of the heart’s electrical preparation for the next beat. I sat down with the patient and discussed the situation.  In the middle of a heart attack, I had to make arrangements for more specialized care.  He would require a cardiologist and a catheterization, perhaps stents or a cardiac bypass graft.

I started the complicated business of sending the patient to a higher level of care while the snow fell hard enough to make the task impossible. I repeated the same story on the phone, each time emphasizing that the patient remained pain-free and with normal blood pressure and pulse.

The snow eased my emotional frustration. No medevac helicopters fly in this health district.  I only ask for fixed-wing transfer when justified by the distance to the facility, and the weather throughout the province assured that the small planes involved in medical transfer could neither take off nor land.  Still, the decision-making came at day’s end.  Vancouver’s cardiologists had no beds, we would have to keep the patient.

As I finished the hospital admit process, the nurse said, “You know, don’t you, that he stepped outside for a smoke.”

No, I hadn’t known. I confess I lost my temper.  I slammed my pen on the desk and stormed out to the front entrance.

I confronted the patient.

Those who have known me the longest will confirm that when I get angry I get articulate, but I rarely raise my voice. I don’t have to.

What I said boiled down to, “You have a beautiful young wife and a son. There are a lot of people who love you, and we’re worried about you.”  But I said it, angrily, about 6 times.

I care about my patients, but I haven’t expressed that kind of fury for years. Maybe I’d worked too many hours with too much noise.  I finished more fatigued, and I felt worse for hours.

The next day the patient thanked me, as did his family. He felt better, the best he’d felt in a year.

Outside, the snow fell thick for the next five days, when, finally, we got word we could transfer.

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.

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.

Appreciating normal: brain tumors, radiation, and the adolescent idiocy of love

October 29, 2018

We don’t know when our career starts careening

Insight is hard when you’re leaning

So slowly life sours

Working too many hours

Contrast is the essence of meaning.

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.

Yesterday a patient (who gave me permission to use as much of his information as I care to) came in for a refill of his prescription for lamotrigine (trade name, Lamictal).

My wife takes the same drug, and their stories carry a lot of parallels.

Dizziness brought my wife to MRI in the summer of 2016. A message on a Friday contained the diagnosis of glioma.  Until the proper diagnosis of meningioma came on Tuesday, I thought my world would collapse in less than 60 days.  During that critical 96 hours I learned how much I love my wife, and since then I’ve enjoyed the adolescent idiocy of being in love, and secure with the woman I married in 1980.

A year after one radiation treatment, my wife started having headaches preceded by a smell and some music; verapamil didn’t help her but lamotrigine did.

My patient’s tumor involved more radiation treatments, and he takes lamotrigine for similar but not identical reasons. He emerged from his treatments a happier person.

I didn’t tell him how, when my wife talks, I smile and listen so attentively that it unnerves her. I savor those moments of normality.

I didn’t tell him that the delight I have in the companionship of my mate stands in contrast to my years of working 84 hours a week. But that contrast remains the essence of meaning.  My time with her now is sweeter for knowing what I missed, and that knowing comes from a close brush with loss.

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The very next patient also grinned his way through the visit. He gave me permission to quote him: “I found some awesome words in my career path. Words like floor, walls, roof, and the best one, heat.  And an open and closed sign, that’s another good one, too.”  He had worked for 11 years without those things.

But I didn’t ask permission to discuss his career changes. Doctors are not the only ones who have trouble setting boundaries, and we’re not the only ones who decide to come in from the cold, whether literal or figurative.

Livers and lotteries

October 26, 2018

You could be a taker or giver
There’s a chance, but only a sliver
You probably won’t pick it
So don’t buy a ticket
Thus to keep a healthier liver.

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.
Abnormal liver tests dominated yesterday’s clinic. Each patient had a different problem, and each went into a different management plan.
The most common liver poisoner, of course, is alcohol. But if a patient credibly claims alcohol avoidance, I have to look for other exposure to alcohol or other organic solvents. I have found a disturbing number of people with medical problems from breathing vapors of Lysol Spray, a product containing 95% alcohol. (Regretfully, many years ago I took care of a patient who later died from liver cirrhosis caused by drinking Lysol Spray.)
Too much food can damage the liver, just like too much alcohol. When rich food has, in the whole of human history, never been so cheap or convenient, NASH, (non-alcoholic steatohepatitis) now ranks second to alcohol for damaging livers. Within the last ten years one of my patients died of cirrhosis caused by overeating.
I still check for hepatitis A, B, and C though a result from those tests hasn’t surprised me for years.
About 1 in 50 people carry the mutation for hemochromatosis, where a person’s DNA fails to code for a signal to quit absorbing iron after having enough. The excess iron ends up in the liver.
Much as a person born with the mutation for continuing iron accumulation after storage reaches saturation, some people don’t know when they’ve had enough alcohol, or food. And some don’t know when they have enough money.
To be rich you must be content with what you have, and, really, without the capacity for contentment a person will always have the drive to acquire more even when not needed.
Even contentment does not suffice to make a person rich. I have met retirees with pensions who have no interest in acquiring more, but they get into trouble precisely because they have enough to keep them from want but they have nothing to do with their time.
The day dominated by liver patients started with news from the US about a lottery jackpot of more than a billion dollars.
At breakfast Bethany and I remarked on the sum, and I said that a pot that large might tempt me to buy a ticket.
Lotteries ruin lives. Losers spend money they can’t afford and find in their losses an excuse to not be happy. Winners gain weight, get divorced, lose their moral compass and see their loved ones die.
So I don’t buy lottery tickets for fear I might win.
But a billion dollars? I could blow it building a medical school to my vision: Hire the most gifted teachers to generate cognitive content for premed and the 2 classroom years, and post online courses at very low cost. Weed excess students by requiring fluency in a second language. Anyone passing Part I of the Boards could apply for a clinical position.
Or, alternatively, I could just keep doing what makes me happy.
And I don’t even have to buy a ticket to do it.

Students playing with slit lamps

October 25, 2018

It’s as simple a one as you’ll find
And I hope that your teacher is kind
Concerning the eye,
Here’s the how, not the why
And playing beats the old grind

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.

Most doctors who take call have superstitions. We talk about not using the “q” word (quiet); to do so seems to bring disaster in the form of swarms of sick patients.

Personally, I will not answer a question about how call is going till I can do so in the past tense; I always say, “Ask me Monday.”

I can now say that call went well. I had the great pleasure of having 3 med students.

I asked the students to gather at the ER at 8:00AM, expecting a patient who didn’t show. With no clinical load, and no time pressure, I introduced them to the slit lamp at 8:30AM.

A slit lamp is, essentially, a stereoscopic microscope for examining live eyes in real-time. In larger centers, with ophthalmology (eye specialist) back up, the generalist has no need to learn to use one.  Because I shy away from those jobs, I have had to learn to use the instruments, and I did so by playing with them.

Slit lamps come in a variety of conformations and complexities; the one we have here appears old, simple and wonderfully functional by comparison to the slick, spiffy ones I’ve used in Alaska.

I showed the students the joy stick that enables a doc to focus on different eye structures, and the switch that changes the light playing on the eye from slit (hence the name) to circle to black light. Then I sat on the patient side of the instrument, put my chin and forehead in the right places, and, one by one, talked the students through the proper use.

Actually, I said, “Take off your glasses and have a play. This is about as simple a slit lamp as you’ll ever find.  We have no time pressure, you have complete support from everyone in the room, and you can’t hurt anybody.  Go for it.”

At the end, 5 minutes of play trumped the half-hour of didactics I didn’t  go into.

After we’d all played with the instrument, they asked when to use the slit lamp. “That,” I said, “Is a much longer talk and is best reserved for your ophthalmology rotation.”

I told stories about grouchy specialists and foreign bodies embedded in corneas. Eventually, I talked about Reiter’s syndrome: inflammation of the eye, urethra, and joints, frequently accompanied by fever and rash.

But I didn’t tell them the whole story about Reiter, a Nazi who did such terrible things in World War II that many in the medical community would like to use the term “reactive arthritis” and make the eponym anachronistic.

We were having too much fun playing with medical instruments.