Archive for the ‘Canada’ Category

Uncertainty usually strikes at least twice

November 2, 2016

Only a second was I left perplexed

And then with the changes I flexed

I know what to do

When the plans all fall through

I ask, What shall we do next?

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. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  Just back from a Canada moose hunt, I’ve worked a couple of days in northern Iowa, and I’m taking a few days off.  Any identifiable patient information has been included with permission.

I have been working on practicing in Canada for 20 months. Six weeks ago I thought I was within 2 months, then 3 weeks ago learned that my case would have to go through immigration because I have no plans to immigrate.  And that their review would take 6 months.

OK, I know how to deal with uncertainty. Bethany and I talked for about 10 minutes, with the unspeakable luxury of discussing, Where shall we go next?

If I had the chance to tell me as a teenager what life would look like 50 years in the future, I would not have believed me saying that such freedom could exist in the real world. We decided on interior Alaska for the winter.  And I decided I wanted to work for the Veterans’ Administration, because they have been so very good to me.

I got on the net, I plugged my headphones into my cell, and I started the process. VA facilities run shorthanded chronically, but the one in Fairbanks no longer works with agencies.  And they are willing to work with me directly.

Over the next couple of days I got emails from several people in the institution with a far warmer and friendlier tone than I expected.

Last week I started the credentialing process. I put in a mere 7 hours, finishing yesterday with a trip to FedEx.

Because I cut the agency out, I’ll have to arrange my own housing and vehicle.

Tonight I talked with a man who specializes in selling cars to seasonal Alaska workers and buying them back when the jobs are done. I’ll wait till things have firmed up till I start contacting real estate agents and other housing mavens.

Yesterday I learned that that my putative Canadian gig had found permanent recruits and wouldn’t need me.

Uncertainty, part of the human condition, runs rampant in the locum tenens business, and struck again in less than a week. Yet from experience I know if something falls through, I generally end up having a better time with my second, third or fourth choice than I would have with my first.

I got out my 3×5 cards and started making notes as I cruised Googlemaps and Wikipedia.

I read stuff to Bethany, and we talked. She doesn’t want to go anywhere reachable only by small plane or snow machine, or that has under 1000 people.  I, in turn, define my professional zone of comfort as less than 2 hours from the nearest surgeon.

We have to have indoor exercise facilities for both of us, internet access, and at least one grocery store. Nice options would include a cinema, indoor archery range, and recreational fishing.  I would like to walk to work, and Bethany would like to be able to get work as a teacher.

We’re looking forward to the next adventure.

 

 

Reverse Snowbirds

October 19, 2016

North we are planning to go

For the experience, not for the dough

If we prefer cold to heat

Can Alaska be beat?

We’ll wait for the dark and the snow.

 

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Yesterday featured a volley of emails and phone calls to Canada.

American liberals love the Canadian medical system; American doctors love to hate the Canadian system. Neither side understands it.  I want to experience it firsthand.  To that end I’ve been working on getting a Canadian license.

Rural areas in both the US and Canada face terrible shortages of medical personnel. Even doctors willing to work in small communities have to overcome enormous hurdles for licensure if they come from out of the country.  In the US, physicians and other skilled workers from other countries bring diversity to the hinterlands.

I wouldn’t bring much diversity to Canada.

After quite a saga, I’ve gotten to the point of talking with a facility in northern British Columbia. They need me, I’d like to work for them, but I have no intention of immigration (though the social fallout from the election could change that).  After I get a formal job offer, the facility needs to file a Labour Market Impaction Application (LMIA) with Immigration.

Yesterday I learned that a realistic time frame for having Immigration review the LMIA and act on it would be six months. I had planned a mid-January start date.

So Bethany and I sat at the table and asked, Where do we want to go?

It took about ten minutes to decide to go back to Alaska, where we have had such wonderful experiences. And, because the window would come smack in the middle of the winter, we decided on the interior, far from the moderating effects of the ocean, where we’ll face cold more intense than Barrow.  Bethany specified she didn’t want to get in a small plane to get there.

I put several items on my original walkabout agenda back in 2010, among them the Veterans’ Administration, because they’ve been so good to me. I let my fingers do the walking through the Internet.

I introduced myself to the clinic manager and asked if she needed any locums. The sunshine in her voice radiated through my cell phone when she said “Yes.”

I specified the agencies I’ve worked with, emailed my CV, and set up a phone interview with the Chief of Staff.

On the phone today I found out that they need me enough to consider working around the lack of authority to make a contract for a locum tenens.

I usually say yes to 6 assignments for every one that actually happens, and I have come to embrace the uncertainty.

Hearing loss and moose hunt

October 15, 2016

There’s a ringing I have in my ears

I sure hope that it clears

Perhaps on its own

Or with prednisone

For deafness is one of my fears

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

We first spotted the moose on a hill about 170 yards from the lakeshore. He moved just before I pulled the trigger.  The guide started to call, and the moose came to us, his antlers swinging at the level of the boreal forest tree tops.

With my crosshairs on the bull’s sternum, I pulled the trigger when the distance closed to 60 yards, and my ears started to ring.

Age-related hearing loss runs in my family. My mother and her mother needed hearing aids before they reached my age.  But neither of them stood in front of the drummer playing sax for an R and B band, hung out in discos, nor had anything to do with firearms.  I could still hear bats at the age of 26, but the highs gradually faded.  I started hunting in my 30’s and after the first few years of firearms use I got conscientious about hearing protection.  Later I bought occlusive hearing aids with a limiter circuit, so I could hear a pheasant taking off or a deer approaching, but nothing louder than 85 db would transmit to my ears.  The devices worked fine hunting pheasants in January.

But they failed to protect my ears from the blast of a 7mm Remington Magnum.

The death of an animal, even a mouse in a trap, always hits me spiritually. I have never killed a moose before, and when he crumpled he left a palpable hole in my universe.

When the moose stopped moving I found my hearing had fled.

Over the next couple of days my hearing improved. As soon as I got home I contacted the audiologist.  He found I’d lost 20 db on the left and 10 on the right.   He adjusted my hearing aids and talked to me about vitamins.

Luckily, I’d already ordered an electronic stethoscope.

The next day I went for acupuncture. But on a physician’s social media site, I posted a question about treatment for acute noise-induced hearing loss.  More than one doc said it served me right for killing such a majestic creature, a thought I had already had.  But a few mentioned steroids.

I never self-prescribe; I called my ENT, and I started steroids today.

I hope they work. I’m not done listening.

Aging truckers and doctors

October 13, 2016

In the land of the poplar and spruce

I saw the eagle, the crow and the goose

I cooled my seat

While they processed the meat

That came from a 30-inch moose

 

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

 

I went moose hunting in Manitoba, and shot a young bull at about 60 yards. (For the firearms enthusiasts, I used 175 grain bullets in a Weatherby Vanguard 7mm Remington Magnum.)  To paraphrase Jose Ortega y Gassett, eating justifies the kill, the kill justifies the hunt.  I really had no idea of the enormity of the northern Canadian wilderness.

I drove north out of Sioux City through Winnipeg to Thompson, about 16 hours. Past Thompson, one can drive east or west but no further north.  An hour by float plane put me onto a lake where the living moose have seen humans only for two weeks last year.

The camp consisted of a wall tent with a wood floor, big enough to sleep two hunters and a guide comfortably.

We hunted by boat, cruising the shore line. I shot the third moose we saw, three days into the hunt.  After that we took care of the meat, went fishing, and loafed.  With no internet, I didn’t post anything though I continued to write.

After the hunt I stayed in Thompson getting the meat processed and frozen. In the Days Inn that Saturday I struck up a conversation with a married trucking couple.  They drive separate rigs together in Canada, and his engine needed work for a day or two.

They love their work, but, in his early 60’s, he’s looking forward to retiring. Over-regulation has robbed the job of much joy.  He finds it no longer feasible to drive in California because a drop of oil onto a white sheet of paper results in a fine and in turning back at the border.  That state stringently enforces emission rules, mostly in the form of expensive inspection stickers.  Log books, now electronic, can no longer be juggled.  While Canada permits a solo driver 13 driving hours per day, the US only permits 10, and he finds it difficult to make driving in the States profitable.

He could diagnose and fix almost anything wrong with a truck made before 1995, but since then computers have taken over the engines. A mechanic needs certification, with a week update training every 2 months.

I sympathized. Doctors, I said, have seen regulation erode earning potential.  Clinical improvement justifies about 10% of those regulations, and the rest just take more time.  Recertification, a hot button issue, occupies more time and energy than it deserves.

Both fields have changed markedly in the course of our careers. The older generation, voting with their feet, is retiring earlier than they had intended because of the problems.

But autonomous big rig trucks will replace human drivers in the next 20 years. Every society needs doctors.  At least for the foreseeable future.

 

Faded Signatures: 4 Months to BC License.

December 6, 2015

They might think that I’ve misstated

Or perhaps I’m just overrated

This back-and-forth trial

For a license denial

Because the ink at the bottom has faded.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer  and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and working Urgent Care in suburban Pennsylvania. Right now I’m in Virginia for the holiday.  Any patient information has been included with permission.

This afternoon I got a call from the British Columbia recruiting agency, and my learning continues.  As it turns out, they have plenty of docs trying to come in and get jobs in coastal BC. Any installation trying to get a locum tenens doctor has to do a great deal of documentation before they get approval, worse if that doc comes from another country.  The bureaucratic hoops seem insurmountable.  But when I told her I planned to go to the northern, interior part of BC her voice audibly brightened.  I might stand a chance, but, in all honesty she said, it will probably be at least 4 months.

I learned that each Canadian province has its own Electronic Medical Record system, and if I don’t get my BC license, Alberta might be easier.

And I explained I might have a problem getting a license.

Last night I received an email from the Canadian website where I’ve sent my credentials.  They want a better copy of my residency certificate.

After 4 years of medical school, a physician who wants to practice goes to post-graduate training, or residency.  Non-surgical specialty training generally runs 3 years, surgical specialties like cardio-thoracic or ophthalmology take 5 to 7.  At the end of my term in Casper, Wyoming, I received a paper certificate mounted on wood and protected by laminated plastic.

The Canadian agency in charge of vetting my credentials so they can be reviewed by other agencies said that they’d looked at the copy of my residency certificate, and they couldn’t read two of the three signatures at the bottom.

My email back to them noted that the certificate had been faded by exposure to fluorescent light for 26 years and sunlight for 23 of those years. The signatures weren’t very legible to start with, and I couldn’t do better than the professionally-made copy I’d sent.

In the 21st Century, due diligence demands verification of all credentials.  The hours of investigation easily justifies the Source Verification Request fee I’ve already paid.  They should not just take my word for it.

I still face the hurdle of poor documentation of my gynecologic training during residency.

But I have a tiger by the tail.  Every application I fill out asks if I’ve ever been denied a license or if I’ve ever withdrawn an application.  So far I’ve answered, in honesty, “no.”  Withdrawing an application reflects badly on me.  But license denial because of an illegible signature doesn’t.

 

 

 

 

Badly kept residency records, and Canadian license

November 17, 2015

On the list I’m making the checks,

I sent for my scores from the FLEX.

There’s loads of email

But the process could fail

On the training of the feminine sex.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I find myself in the process of applying for a Canadian license, specifically for British Columbia.

I want to experience the Canadian system first hand, and compare it to the realities of the current US system.  Then I want to write about it.

That Canada has a national electronic credential depository called PhysiciansApply.ca makes sense.  I suppose I should have looked more carefully to find the SHARE DOCUMENTS button.  Today I found it and used it.

I don’t blame them for wanting letters from my employers for the last three years, documenting scope of practice and hours.  But how would that work if I had been self-employed during that time?  Actually, I was self-employed during that time; I got pay checks from the locum tenens agencies but as an independent contractor.  Positive they didn’t want me verifying myself, I sent emails off to the agencies.  All of them.

In the summer of 1979, I took a 3 day examination called the FLEX in downtown Denver, Colorado.  About 250 well-educated doctors came together in a cavernous hall.   All the other tests I’d taken up until then counted for nothing more than practice.  I remember that every 45 minutes or so I would have to put down my pencil and shut my eyes for 30 seconds so that I would start caring about the test again.

The Canadians want the original score from that test, and I suppose I can see their point.  I got that task done with a brief Internet search and a credit card outlay of $70.

The licensing process may very well fail on the faded records from my residency.  I had 18 weeks training in Obstetrics, but gynecology didn’t warrant any kind of mention.    And the College of Physicians and Surgeons of British Columbia wants to make sure I had adequate training.  Even though 90% of what I learned then is now incomplete, hopelessly out of date, or just plain wrong.

I spent a long morning on the phone and at the computer, making calls, leaving voice mails, asking for letters and certifications.  Without exception, the Canadians I talked to were polite, friendly, professional, and well-trained.  Their gentle reassurance carried the message that things would be fine, and my license will happen.

I keep an open mind.  If this adventure doesn’t work out, something else will.

I lunched with a colleague who works ER.  I picked his brain for stories of real major trauma.  While we talked about medications, management, techniques and tools, we couldn’t escape the discussion of drama, irony, and tragedy in the face of human bodies damaged by the inevitable truth of physical laws.

 

Working On My Canadian License

November 10, 2015

They have no reason to trust,

To verify is certainly just

They’ll get verification

For each certification

And fill out the forms, well, I must.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

After a surprise two-day stint in Pennsylvania, I returned home.  I had a good conversation with a doctor in southern Alaska; I had signed up for a couple of weeks but hadn’t had a phone interview.  At the end of the call, I decided that the frequency of major trauma and cardiac arrests would put the assignment outside my skill set.

I discovered to my horror later in the day that my Advanced Trauma Life Support (ATLS) certification had lapsed 6 months ago, and, without that credential, I couldn’t have accepted the job.

I got on the net and the phone and I located a course in Kansas City, with one opening.  I took it, but, strangely, I’ll have to pay by check.

I also worked on my Canadian application.

I have three web accounts going: one with the British Columbia agency that can put me in touch with facilities needing my services; one which serves as a depot for my credentials; and one responsible for a BC license.

The third account assigned me a user name consisting of a 12 digit number.

I have had to upload a copy of my medical school diploma, my Iowa license, my residency certificate, my board certificate from the American Board of Family Medicine, and certified copies of my passport, along with recent photographs.  Each professional credential required a face sheet and the payment for a Source Verification Request.

Two weeks ago I sent a packet with those papers.  But copying outsized documents like medical school diplomas and board certificates and residency certificates leaves things out, they said, and I would have to resubmit.  Along with the face sheets.  But I could do so electronically.

Confused by parts of the websites, I call frequently.  I talk to polite, professional, helpful, knowledgeable people.  They admit that some parts of the process don’t make sense, and they help me through it.

In the 21st Century, they shouldn’t trust anything I say nor any of my documents; I understand the Source Verification Request business.  I look forward to the time when I can just send my CV and pay an investigation fee.

And I’m not complaining.

My most recent US state license involved my submitting the same information electronically 4 times and by registered mail 3 times.  And the people I dealt with on the phone weren’t nearly as polite as the Canadians.