Archive for the ‘Canadian Adventure’ Category

March 10, 2019

I had me a weekend on call

With patients good-looking and tall

As the assignment will end

A free day I’ll spend

And perhaps I’ll return in the fall

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.

I had call for this locum assignment’s last weekend. Things started abruptly with three complicated patients already in Emergency.

Over the course of the weekend I hospitalized one patient overnight.

Winter sports generate their fair share of injuries. Despite good protective equipment I took care of hockey players who encountered a basic truth of the universe: two objects cannot occupy the same space at the same time.

I have not seen nor heard of a curling-related injury. That sport has limited following in the US, perhaps because of its lack of violence.

Newton’s 3 laws (a body in motion remains in motion unless acted on by an external force, a body at rest remains at rest unless acted on by an external force, and every action has an equal and opposite reaction) applies to skiers and snowboarders, no matter how good-looking they are.

Canada legalized marijuana less than a year ago. The legal stuff carries high potency, and comes at an affordable price.  I cannot for the life of me figure out why anyone would run the risk of illegal adulterated weed in the face of accessibility of a relatively pure product.  But some people do.

In other places, at other times, I’ve taken care of people who consumed so much alcohol that they lost consciousness during winter snow falls. Brought to the ER, the ambulance crews could estimate the length of time they had been exposed to the cold by the depth of the snow that had accumulated.  Not one of them developed frostbite.

Which does not mean I don’t see an occasional case. The most memorable one came one summer in New Mexico, when the patient, bitten by a rattle snake and ignoring instructions to keep a layer of cloth between skin and ice pack, froze the top layer of skin.

When the sun came up Monday morning I could account for a decent 6 hours of sleep.

The weekend call doctor here gets Monday off. After a leisurely breakfast, I came in about 9:00AM and started working on clearing up administrative odds and ends.

The office manager found me after lunch, hard at work rewriting a referral letter that I’d sent to the wrong specialist, not realizing two had the same distinctive, 4-syllable name.

The government covers rural physicians for 43 days of yearly locum tenens, running from April 1 to March 31. She explained that my Sunday call exhausted that particular account.  Tuesday, this assignment’s last day, could not be paid for.

I grinned.

A day off.

Part of the adventure.

 

 

 

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A Full BC license

February 1, 2019

A full license the College did grant

I could work elsewhere, but I shan’t

At home, with a friend

I saw a Parkinson’s trend

A tremor, and a walk with a slant

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

Much has happened in the two weeks since I last posted.

I got my full BC license on January 17th. Up to now I’ve been working with a provisional license, which requires that I have supervision and work in 3 month blocks.  The licensing authority waived the requirement that I be a permanent BC resident.  Technically I now can work in other parts of the province.  Still, I would have to ask myself why I would want to go anywhere other than the most functional medical community I’ve ever experienced.

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We got back to the States on the 20th.  The mountain of unread mail made procrastination unfeasible.  I sorted it into piles of WILL READ and RECYCLING.  Having been gone for the December holidays, we also had a few gifts.

At this stage of my career, having accumulated too much, we need very little. So if someone wants to buy a present, we’ve taken to saying it should be expendable, negotiable, edible, biodegradable, or inheritable.  Imagine our surprise when we got a really nice cutting board.  Which, strangely, we can use.

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I have noted an alarming increase in Parkinson’s in the general public. When I finished med school, the vast majority of Parkinson’s disease came from the Great Influenza of 1918.  In the ‘80s you could pick it out in a crowd just on the basis of age and gait.  Than generation has passed.  Saturday, at a social gathering, I glanced at a friend’s hand resting on a lectern, and spotted the characteristic tremor of her right hand.  Over the decades I’ve known her, I failed to note the gradual loss of facial expression.  When quizzed she confirmed anosmia (loss of sense of smell), micrographia (shrinking handwriting), bradyphrenia (slowed thinking), and loss of balance.  She also gave me permission to write about her in my blog.

And from time to time, in an airport or grocery store, I’ll point out to Bethany the telltale leaning, shuffling gait, and blank stare.

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My wife and I do better with cold than heat. We flew to Texas to visit our (doctor) daughter, her (doctor) husband and their children.  We left Omaha at a temperature of 1F (-17C) and arrived in Houston to 47F (8C).  We happily walked around in our shirt sleeves while the locals wore parkas, ski caps, and mittens.  Two days later, I reverted to wearing my winter jacket, but not my long underwear.

Contrast remains the essence of meaning.

New Year’s lacerations

January 3, 2019

I said to my very next case

With a cut so bad on his face

He got from a grinder

Do you suppose that it’s kinder

To use stitches to close up the space?

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 approached the third laceration patient of New Year’s Day on call. Lacking a bolt cutter, the patient had been using a power tool called a grinder to cut a bolt for a friend.  Living flesh suffered in the slip that followed.  The wound gaped straight down the midline of the chin and onto the upper part of the neck.

I said, “You got two choices. The risks of the procedure include infection, bleeding, pain, and the certainty of a scar.  The risks of not doing the procedure include infection, bleeding, pain, and the certainty of a scar.  Your choice.  Shall we proceed?”  The patient agreed.   While the patient’s wife took cell phone pictures, I cleaned and numbed the area, then held the wound open for the camera.

“Is this already on Facebook?” I asked. The patient and wife both laughed.  I said, “Then if it’s already on Facebook, is it OK if I write about it on my blog?”  They both agreed.

I put on my headlamp, slipped off my glasses, slipped on my gloves, and started stitching. Suturing fell into a rhythm: sew, tie, cut.  Between the cut and placing the next stitch, I would ask a question and the patient would reply.

We talked about ice fishing and the discomfort inherent in the activity. I made the comment that I’d been out on the ice while others fished, but, aside from the Inuit, it seemed like beer constituted the main reason to bring poles and bait outside.

We all laughed, and I said, “Ten thousand comedians out of work, and you got one with a stethoscope.”

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Bad call put my senses into a time warp. This morning I awakened thinking I had call again, not realizing till almost 9:00AM that I had clinic.

My morning’s highlight, which put a bounce back in my step, came when I met with a man I’d diagnosed with Parkinson’s last month (and who gave me permission to write about him). His stiffness melted, leaving behind a more fluid gait, clearer speech, a mobile face, and better balance.

He’d had a stroke a couple of years ago, and in the aftermath he started having auditory and visual hallucinations. The rehab staff told him that, 9 times out of 10, nursing home placement follows one spouse finding out the other hears and sees things that aren’t there.  So he’d kept his hallucinations to himself.  But they’d stopped right after he started carbidopa/levodopa (trade name, Sinemet) that I prescribed for his Parkinson’s.

Even though in the last year I’ve helped dozens of similar patients, each one reminds me of why I’m a doctor.

 

Watching a couple lay foundations of abuse

December 17, 2018

I know it’s just not my place

To go and get in the face

Of the emotionally unstable

At the next table

They’re just not my clinical case

 

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.

 

The last to arrive, I got the seat at the end of the table. We gathered to celebrate the final day of work for a Family Practice resident who had come for a rural experience.

I sat down just after the waiter came with my pre-ordered sandwich. I found my colleagues wondering about me.  I explained I missed catching a ride to care for a last-minute patient, and I enjoyed the exercise of a snowy kilometer’s walk.

The conversation centered at the other end of the table, I reveled in the leisurely meal and watched the dynamics around the room.

I can write about these things because they happened in a public place.

A young woman tried to distance herself from the affections of a young man. She leaned away from him, he put his arm around her shoulder, she resisted his efforts to pull her closer.  He scooted in, she leaned further.  He tried to put his head on her shoulder, she did push him away but her posture told me she did not welcome the closeness.

The young man clearly did not understand, and did not want to understand.

I watched a couple lay the foundations of an abusive relationship. The courtship’s emotional intensity stems from the amount of work one party has to put into getting the other party’s attention.

I could read immaturity in the young man’s body language; he acted like a 15-year-old in a 25-year-old’s body. The resistance to his advances would strengthen his interest, leading to a pathologically intense courtship.  Once locked into a love interest, he would lose perspective and sensitivity.

I have seen the consequences of such scenarios at various stages of development. Pathologic fixation on another person with inevitable human imperfections gives rise to uncertainties, then disappointments, then hurt, then abuse.  The young woman may court intensely; the abuse may flow emotionally, verbally, or psychologically.  It rarely flows one direction, and always spills out of the home, rippling through families and communities.  I see the physical impact clinically.  People get sick as an end result of such courtship, sometimes generations and continents away.

I want to go over and tell the young man to grow up, and tell the young woman that if she cares at all for him, she should drop him now and not lead him down the path of destructive love that will crush both their souls and mangle their bodies in the process.

But I don’t. I sit in a public place and watch people who aren’t my patients while I munch my crispy chicken sandwich and make small talk with a colleague.

Eye color change, addicts with insight

December 11, 2018

A change in the color of eyes?

It comes as quite a surprise

It can happen, it’s rare

It’s more common in hair

Don’t count on it for a disguise

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 found myself on call this morning, glad that it came as a surprise so I didn’t have the anticipatory anxiety the night before.

I recognized a person who came in accompanying an ER patient, but I had problems with the appearance.

I had seen the patient weeks before, with a very puzzling physical finding, and tonight I got permission to blog about it.

Presenting complaint: eye color change. I hadn’t heard of such a thing, and I hid my skepticism.  But I did ask for the driver’s license, which confirmed eye color as hazel.  Yet the patient, without a doubt had blue-grey eyes.  I posted an inquiry on a doctors-only clinical social media website.  About half the responses derided the very idea.  But one ophthalmologist offered an erudite discussion and attached a link.

Indeed, eye color can change.

So I thought it over. Eye color depends on little packets of pigment called melanosomes.  I already knew that some unfortunate people can lose color from patches of their skin in a process called vitiligo (two prominent examples include Michael Jackson and the Pied Piper of Hamlin).  And if a person loses a patch of hair to alopecia areata but the hair grows back, it will usually grow back white, due to a loss of melanosomes.

So, if that can happen in the skin, when not the eye?

The patient’s eye color had since darkened, now having bits of brown and green, enough to throw off the appearance.

I said that discussing such a rare finding would come close to identifying a patient.

The person happily gave permission for me to write about the incident in my blog, and talked about running into others who similarly had seen their irises go from dark to light.

Eye color change happens little more rarely than addicts acquiring insight, yet for the 7th time in a week an addict came to clinic knowing change was needed, having started the change, and requesting counseling.

Note: this post made it into the draft queue and marinated there for more than a week.  Since then I’ve had 5 more addicts come in with insight, requesting counseling.  Some have already started going to meetings.

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.

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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.

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.

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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.