Eye color change, addicts with insight

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 4^th 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 7^th 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.

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Vice-Grips as a surgical tool

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 4^th 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.

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

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 4^th 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

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 4^th 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

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 4^th 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 11^th minute of the 11^th hour of the 11^th day of the 11^th 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

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 4^th 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.

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 4^th 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.

On marijuana, wages, and education

Here’s what to learn from the sages

Education is not just about wages

Your life it makes richer

For the depth of the picture

And it keeps your mind out of cages.

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 4^th time.  Any identifiable patient information has been included with permission.

Medical school starts with 2 years of classroom study, with little actual patient care except classes in interviewing and physical exam. Third year brings the cataclysmic change to clinical work: one month you sit in lectures and try to absorb as much as you can, and the next month you deal with people who bleed, vomit, cry, and sometimes die.

My medical school, based in East Lansing, sends 80% of the medical students to smaller communities for those crucial two clinical years. I went to Saginaw.

At the time, the automobile industry dominated the town. Up till then I had always lived either in big cities (not my favorite) or college towns.  Saginaw changed my context radically; I ran into a lot of blue-collar workers on a daily basis.  I had left my bubble.

One of my classmates, having grown up in Michigan, remarked that one of his high school classmates started working in an automotive plant at age 18, and a doctor would have to work till age 45 or 50 to match lifetime earnings.

I recall a millwright on the internal medicine service who made as much money as the attending physician, and worked much better hours.

Fast forward 42 years, and Bethany and I have landed in a different mill town.

Bethany substitute teaches. She found the elementary students polite to the extreme.

But she has concerns about many of the middle and high school students, concerns she shares with the administration. A lot of students don’t engage in class because as soon as they turn 18 they can start high-paying mill jobs.

My grandfather had a talk with me before I went off to college for the first time. A man so wise that even as a truculent 18-year-old I recognized his wisdom, he said, “You don’t get an education to earn more money.  You get an education because an educated man leads a richer life because he understands what he sees.”

Few people have a grandfather like that, and fewer still come from a cultural background that values learning for the sake of learning.

Of the 18 patients I attended on Friday, while the season’s first heavy, wet snow hushed the town, 14 abuse marijuana, using it multiple times daily. Of those, 12 have high-paying factory jobs, and of those, 10 have chaotic homes.

I don’t know where to look for causality, to the weed, the wages, or elsewhere.

But I do not think making marijuana legal will do anything positive to engage the students in school.

 

Small non-miracles

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 4^th 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

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 4^th 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.