Archive for the ‘Canada’ Category

Teaching 3 things I didn’t learn in med school

February 26, 2019

The student might have thought I was mad

When I lit up an alcohol pad

And then used that fire

To heat up a wire

But then I made happy the sad.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

Some of the docs here have decided to split weekend call so as to avoid working 72 continuous hours, a step I regard as so healthy that I volunteered for Saturday call last weekend. I had the chance to teach a medical student, Dyon, who intends to do a Family Practice residency.

All patients mentioned gave permission to write about their cases.

The first patient came in with a subungual hematoma, or blood clot under the finger or toe nail. A very painful problem, but one easy to cure by putting a hole into the nail.

The nurses couldn’t find the usual tool, an electrocautery, which looks like a disposable electric soldering iron.

I taped an unfolded paper clip to a tongue depressor with 3cm of wired extending past the end. In the absence of a Bunsen burner, I turned an alcohol pad into an alcohol lamp by tearing a corner from the foil packet and lighting it with the patient’s cigarette lighter.  The student, in his capacity as fireman, held the flame close at hand.  I kept the paper clip tip in the hottest part of the flame till it glowed, and applied it to the nail.  It sizzled nicely but cooled too quickly to go all the way through.  The first “alcohol lamp” burnt out before resolving the problem.  Then the patient volunteered to keep his lighter burning.  On the 3rd try, the glowing metal melted the nail, and close to half a teaspoon of dark red blood spurted free.  The patient, like most in his situation, had such relief that he started to chuckle, probably from endorphin rebound.

In short order we faced an 11-month-old, and another chance to teach. When babies, about 10 months old, distinguish family from non-family, they fear strangers.  While humans can see from birth, it takes till age 9 to fully organize the information coming from our eyes.  Thus, if you don’t make eye contact with a 10-month-old patient, you can examine the ears without force or trauma; they think if they can’t see you, then you can’t see them.  The trick worked on the 11-month-old.

About an hour after, an adolescent arrived with a toothache. Standard treatment consists of pills for pain and infection; in addition I showed the student, the patient, and the parent how to find the acupuncture point that the Chinese call Ho-Ku and that Western anatomists call the branching point of the superficial radial nerve.

For all three patients I got to show off knowledge acquired outside of medical school.

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I’m the doctor. You need the dentist.

January 15, 2019

It doesn’t take much of a sleuth

When it comes to a pain in the tooth

In the head, but not mental

Those problems are dental

They start in the mouths of the youth

 

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’s recognition of care as a right means that cost comes out of everyone’s taxes, and, in that sense, everyone has health insurance.

(Actually, they don’t. The Mennonites, for example, do not have to pay those taxes.  And I ran into a young man with such massive self-defeating behaviors that he procrastinated getting his insurance card for 4 years.)

The mainstream plan does not cover dental work.

The bigger employers offer dental insurance, but, like the US dental insurance, it has a high deductible and large copay. Thus people tend to ignore their teeth.

I see between two and four patients a day with dental problems; a higher percentage when I’m on call. About a quarter of those who come in with toothaches have never visited our facility before.

If people didn’t hurt a lot, if they could get in to a dentist close by, they wouldn’t come in to ER with dental pain. When they open their mouths, I see decades of procrastination and neglect.  Broken teeth, teeth rotted to the gum line, teeth worn out from the clinching that methamphetamine brings.

I can’t actually fix the problem. I can give antibiotics and pain relief.  Amoxicillin remains the standard in dental infection.   For analgesia, I have the nurse administer ketorolac (Brand name, Toradol) 30 mg as an injection, and I give the same medication as a pill for 5 days.

If time permits I show the patient ho-ku acupressure, squeezing a point in the muscle between the thumb and forefinger, which relieves head and neck pain.

But I have to urge them to get into the dentist as soon as possible. For those who can’t afford to pay, I give them information on the free dental clinic held twice monthly in Prince George.  Staffed by volunteers, they rarely have time to do anything besides pull the offending tooth.

I suppose I could learn to do dental extractions. If I did, in short order I’d be doing almost nothing else.

Some of the patients don’t have a problem till they’re about to head into the wilderness for work for a few days; I generally give them a longer prescription of Amoxicillin, but I don’t give out pain pills that would make them dangerous around machinery, or driving to Prince George.

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.

Vice-Grips as a surgical tool

December 10, 2018

He came in with a tree in his heel

I didn’t ask, How do you feel?

But I got a good grip

At the end of the stick

And yanked.  And I did it with zeal.

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.

People sustain damage in such unlikely ways I would be ashamed to write them into a script. The young man involved gave me permission to tell his story.

Working in wilderness areas where bears and wolves constitute more of usual hazard than anything on the ground, he stepped off a log onto another, not realizing that a dead branch projected directly into his landing zone. The sharp piece penetrated the industrial-rated sole of a new boot in good condition, into the foot just in front of the heel bone, and exited right next to the outside ankle bone (lateral malleolus, if you must).  He crawled 300 meters (three football fields with end zones).  His boss drove him 4 ½ hours to our facility.

The thick end, about half an inch around, stuck out half an inch from the skin.

Of course I called for help. The orthopedist in Prince George advised us to remove it, give the patient antibiotics and pain pills, and make sure he arrived ready and in time for surgery the next morning at 8:30AM.

I know a lot about procedural sedation, but I’ve not done one, so I called for more help.

While I waited, I got to thinking about exactly how to grasp the spear at its base. I located the biggest needle driver and the toughest-looking Allis clamp, but neither appeared up for the task and I wished out loud for a pair of Vice-Grips.

Check Maintenance, the nurses said.

Finding the Maintenance door locked, I discovered to my amazement that my key for the Doctors’ Lounge opened it. From the drawer marked PLIERS I extract a Vice-Grips, a Channellocks, and a pair of industrial-grade Stanley pliers, thinking that all those years as a bicycle mechanic finally paid off.

My colleague graciously came in, talked me through the anesthesia set-up, and watched as I administered fentanyl (a powerful, short-acting narcotic), and propofol (a general anesthetic). When the patient quit answering questions, using my experience with Vice-Grips and metal, I got a loose fit, tightened the locking pliers half a turn, grasped the projecting end of the stick and yanked.  The stick exited cleanly though blood-covered, just a bit longer than my palm’s-width.

Despite heavy anesthesia, the patient sat up and talked without making sense, then after 15 seconds lay back down. When the general anesthetic wore off, he did not remember.

I brought the tools back to Maintenance, and took a good look at their tool drawer.

tool drawer december 2018

Note the needle driver, hemostat, and surgical scissors juxtaposed with Vice-Grips, Channellocks, wire strippers, and tin snips.

Contrast is the essence of meaning, especially in a hospital maintenance department.

Gentle cold and frustrated pagophilia

December 4, 2018

So rare has the story been told

You can ask, is it fool or bold?

Those pagophiles

Travel thousands of miles

Trekking north to seek out the cold

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.

A thermophile, one who loves warmth, doesn’t deliberately head north after the autumnal equinox. In fact, such a person would go south in the winter.  The language has acquired a term, snow bird, to refer to the millions who yearly flee the snows of the north.

So rarely does the opposite migration happen that I didn’t come across the proper term, pagophile (a person or thing who loves cold), until a few months ago, in a book describing people who deliberately set out to experience the Polar Regions in the winter.

Bethany and I discovered our pagophilia in the winter of 2011, when we landed in Barrow (now Utqiavik) a week before sunrise.

We arrived here in northern British Columbia in October, and though we had a dusting of snow early on, gentle cold has prevail with the temperature has hovered around freezing for the last couple of weeks. We’ve had some more snow, but we’ve also had rain.

In the last four days I’ve enjoyed the plunging mercury, finally in the negative double digits Celsius (about 14 Fahrenheit). Snowflakes fall dry, but I’ll have to wait for colder weather to frost my beard.

We’re still sleeping with the heat off and the window opened a crack.

+-+-+-

A lot of Americans complain about the US Postal Service, but in fact the US delivers packages reliably in less than a week. Even during the December retail madness, a slow package arrives in 2 weeks.

Canada mail moves slower, perhaps because of greater distances, sparser population density, or less well-developed roads. Or maybe we have a distorted view because the mail has to go about 500 miles from Vancouver to Prince George, (about the same distance as Sioux City to Dallas) before it can get loaded onto trucks for delivery out to the smaller towns.

Right now Canada Post faces a “rolling strike” by workers in 4 major cities, Victoria, Edmonton, Halifax, and Windsor. Theoretically, the workers only strike 24 hours at one of those centers before moving on to the next, but in fact the work stoppage has slowed parcel delivery down from its usual laid-back stroll to a crawl.  People talk about ordering from Amazon, prepared to email pictures of presents.

Of course, any package attempting to cross the border will run into a time warp worth of a science fiction story.

Malignant materialism: Black vs. Plaid Friday

November 26, 2018

Thanksgiving? Not all that you’ve heard

And the turkey’s a much larger bird

A gift for your grad?

For Friday’s now plaid.

For the local business assured.

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 celebrates Thanksgiving the second Monday of October. Feasts commonly include turkey, squash, vegetables, and apple pie; regional variations include salmon, wild game, Brussels sprouts, wild rice, unique local foods, and what Americans know as New England boiled dinner.

The narrative of the Canadian First Thanksgiving has to do with Martin Frobisher’s successful landing with more than a dozen ships on Baffin Island.

The US Thanksgiving holiday comes the third Thursday of November. The common story of the first Thanksgiving includes the Pilgrims inviting the Wampanoag to a meal celebrating the first corn harvest.

Not surprisingly, the Wampanoag tell a different story that sounds more likely, having to do with irresponsible celebratory gunfire, checking the wellbeing of the vulnerable English, and fishing and hunting in the process. Particularly ducks, geese, turkeys, and deer.

Deer haven’t changed but turkeys have. Since 1950, average slaughter weight has more than doubled, from 13 to 29 lb.

The holiday itself has morphed with the times; religion, hunting and gunfire for the most part have dropped away, replaced by a prolonged, sedentary feast followed by a commercial feeding frenzy. All with a prolonged football binge.

Canadians, like their southern neighbors, kick off their big retail season with the day after American Thanksgiving, calling it Black Friday.

I went to work this year when my friends and relatives in America went out of their way for arguably the biggest meal of the year.

I found it a day to be thankful, without overeating. A hospital patient went home.  I got along with my wife, my colleagues, my patients, and my co-workers.  I walked from a decent dwelling to a decent work place without fear for my physical safety.   I got to see patients improving, and I witnessed the miracle of more addicts coming to insight.

The next day my arrival in clinic started with an accusatory, “Where’s your plaid?”

“P-plaid?” I asked, noting the surrounding tonsorial color scheme indeed dominated by plaid.

Plaid Friday, they told me, celebrates buying locally.

I shrugged. I don’t own anything plaid in Canada.  My general abhorrence of malignant materialism, combined with hundreds of snow-packed kilometers between me and the nearest Wal-Mart made supporting Plaid Friday easy.

Finding myself on call till 6:00PM qualified as the biggest surprise.

 

 

 

Fingerprinted by the Royal Canadian Mounted Police

November 22, 2018

The Constable, he offered a link

He was trained, thank goodness, in ink

A true pro, that Mountie,

He declined my bounty

And we agreed on the evils of drink.

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 went to the Royal Canadian Mounted Police to get fingerprinted today.

I had my finger prints taken first in 1970 by the Sheriff’s Department in Geary County, Kansas, having been booked on the charge of Illegal Pedestrian. (Neither the Court nor the Sheriff has a record of the offense.)  The Indian Health Service required another set in 1982.

Between the summer of 2010, when the Samuel Simmonds Memorial Hospital management sent me to the police department of Barrow (now Utqiaviq), Alaska, for 4 sets of prints, and the summer of 2015, the fingerprint paradigm shifted. Instead of special ink and paper, the FedEx installation used a digital device.

(That particular installation in Pennsylvania got hacked, and all my personal and security data got leaked, including my fingerprints.)

As I’m applying for a Texas medical license, the Texas Medical Board wants two sets of fingerprints, the old-fashioned way. I had to stop by the Royal Canadian Mounted Police station.

A few of the larger cities in Canada maintain their own police forces, but most jurisdictions find contracting with the RCMP more cost-effective.

I have had nothing but favorable experiences with law enforcement in Canada. The Mounties maintain a unique blend of professionalism with friendliness.

The RCMP branch opened at 8:00AM. I had luck, the Constable had been trained in paper-and-ink fingerprinting before the digital revolution.  I had to give my height in inches and weight in pounds; we couldn’t be sure that Texas would know what to do with metric dimensions.

In the States prints cost $10 to $25, depending on quantity and agency. I reached my fresh-washed hands into my pocket for cash, but the RCMP declined payment.

I told the Constable about my adventures, and my plans to do locums with my daughter and son-in-law in Galveston on the Gulf Coast. Most people like warm climates and the Sunbelt, I observed, but my wife and I thrive in the cold.  Then I talked about wanting to work in Nunavut, the northernmost and largest Canadian territory, but nobody answers my emails.

He has connections in Nunavut, he said, and said he’d send my contact information on. After all, we agreed, not very many docs want to go there.

I left the RCMP station with a bounce in my step, impressed again by an institution that blends professionalism with friendliness. I have hope that the meeting will help me network.

.

 

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.

 

 

Permit, license, insurance, and a contract with the Queen

October 7, 2018

I ended up feeling so keen

For three things, together they mean

I no longer lurk,

But I can come out to work

After my contract I sign with the Queen.

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 50th High School reunion, and a 4-month assignment in northwest Iowa, I have returned to Canada.  Any identifiable patient information has been included with permission.

Monday morning I strolled over to the clinic, marveling at my first snowfall of the year.

I had submitted my work permit electronically to the College of Physicians and Surgeons of British Columbia (CPSBC), which they required before reactivating my license.

I got my new passwords arranged. I’ve done 18 new electronic medical record (EMR) systems in the last 4 years, and, having been away from this one for the summer, I spent the morning practicing.  Mickey Mouse’s name turns up as an imaginary patient in a surprising number of EMRs, including this one.  I entered the diagnosis of felinophobia (fear of cats), and practiced ordering prescriptions, lab, and x-rays. I strolled around the hospital and greeted staffers.

I checked my email every 15 minutes for a reply from the College.

I walked back to the hotel for lunch and a nap. Still unlicensed, I returned to the facility.

By the end of clinic hours boredom set in. One of my colleagues called the College on my behalf.

Tuesday came as a replay. Clicking the REFRESH button every 15 minutes doesn’t count as exercise, and by noon I had started to ache from inactivity.

And I didn’t have cases to talk to my colleagues about. I missed being one of the cool kids who has stuff to talk about.

In the late afternoon my email lit up with notification of license reactivation, but I also had the chance to talk with the College about the possibility getting full licensure, making it return more flexible and shorter assignments possible.

I get my professional liability insurance through the Canadian Medical Protective Association (CMPA), based in Ottawa, 2 time zones to the East. So I called them at 6:30 Wednesday morning (8:30 their time), and by 6:35AM I had insurance.

At 8:00AM I strode into the clinic, grinning. In front of witnesses I signed my contract with Her Majesty, the Queen of England, and started into work.

I took care of my first patient of my return before the official start of clinic hours. I got permission to write about the problem, Eustachian tube dysfunction: the pressure in the ears which follows a cold or allergies and for which no effective medication exists. (Insurance rarely covers the only effective treatment, the EarPopper, a device that “pops” the ear, and costs over $300).

PTSD, chronic med refills, adult immunizations, and discussion of complicated endocrine investigations should not come to walk-in clinic. But they did.  At about 10:00AM I had a patient with a true urologic emergency, when I was running and hour late.

The day didn’t get less frantic after that, and I missed lunch.

I vastly preferred the action of the jam-packed day to the boredom that preceded it. And, at the end, I had cases to talk about, just like the cool kids.

 

Talking Canadian Licensure With a Canadian

August 31, 2018

To her home the doc wants to go back

It took time, but she’s facing the fact

She has nought left to prove

So she decided to move

I told her she just needs to pack

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

I had a good long phone conversation with a Canadian national, a physician working in the States considering going back home, for a lot of reasons.

Right now she attends patients in a high-crime area with brutal heat and humidity, in the sunniest part of the sun belt. She loves teaching, and she loves medicine.

She talked about her aging parents in Ontario. She asked me about scope of practice and professional climate for docs seeking licensure in Canada.  And how to go about the process.

Honesty seized me. I couldn’t talk about her specialty or academic medicine at all. I could barely talk about big city medicine.  I told her how much I loved my spot in northern British Columbia and what huge hassles I’ve been through to work in Canada.

I couldn’t tell her what difficulties she’ll find getting licensure in Ontario, because Ontario is not British Columbia. After all, my Alaska license came easily, my Pennsylvania license did not.   She will not face the 5 months of ricocheting emails caused by hard-to-read signatures on 35-old-residency certificates, nor another 5 months of frustration caused by accidents of history in the development of Family Practice training.

She probably won’t face a 7-month dead-end with a private recruiter.

She won’t need a work permit because she’s Canadian, and she probably won’t need a physical.

We swapped bits of our backstories. I talked about how my curiosity got me north of the border to start with, but how the practice climate keeps me coming back.

We talked about how the insurance industry and government (under the guise of Medicare) used the Electronic Medical Record systems to steal the joy from medicine. We face rapidly expanding nets of regulations that demand more work but do nothing for patient care.

In the end, we agreed that we love the work despite the administrative hijacking.

When I hear American physicians whine, I tell them they can move, quit, go to Direct Patient Care (where the doc gets paid out of the patient’s pocket), keep whining, or just lay back and take it.

The Canadian internist arrived at the same narrow list of choices, and decided to move back home.