Archive for the ‘Locum tenens’ Category

Knowing when to stay and when to go

February 4, 2017

You know what happened? A lot!

I missed that government spot

At least for right now

But time might allow

Me to get the position I sought.

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, the fallout of certain Presidential Executive Orders has me cooling my heels at home. Any identifiable patient information has been included with permission.

At one time I asserted that if I woke up Monday morning with nothing planned I could have work by Wednesday. In fact I’ve found a 2 week lag time between decision and employment.

Last week I gave up on taking a government position in Alaska for the winter; too much uncertainty followed the Presidential hiring freeze. I talked to my agent (more accurate than the title Recruiter that she gives herself).

A lot happened in 48 hours. I found out at least 3 places where I worked and had a good time had recruited permanent docs and didn’t need my help.  My agent opened up a discussion with an installation south of here that will offer me both inpatient and outpatient work.  I talked to them, we hit it off, I said ‘yes’ to the job.  Shortly after that I got an Alaska job offer, but I’d already committed to Iowa.

I asked for and received a 4-day work week, probably close to 40 hours, and the chance to come home on the weekends. Bethany will come with me for most of the trip.

In the meantime I miss the strong cold of the northern clime. The temps here drop into the teens at night, but days have been sunny and while long underwear has become a routine part of my wardrobe I haven’t even thought about bringing my parka out.

The last couple winters I spent in Alaska, and somehow being away from home made the cold easier.

Last week I talked with an agency seeking a permanent placement in a spot 35 miles from here; MapQuest more accurately put the distance at 75 minutes, too far for me. I have thought about telling my agent the name of the facility to see if they want a locums, but I’m concerned about the ethics.

I started correspondence with a firm who wants to place me in a hospitalist job in New Mexico. The position looked reasonable, it would give me a chance to visit the places I knew and loved during my Indian Health Service days, as well as speak a lot of Spanish and maybe renew my Navajo language.

And, with all this going on, I seem to be making progress on my planned Canadian employment.

No matter where I go, I’ll have an adventure.

 

Executive order puts me between jobs

January 31, 2017

A federal hiring freeze

Has put my plans into a squeeze

It was signed with a smirk

But I just wanted to work,

For the Vets with a cold or a sneeze.

 

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. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, the fallout of certain Presidential Executive Orders has me cooling my heels at home . Any identifiable patient information has been included with permission.

Usually Washington decisions take months to influence my life, the ship of state does not turn on a dime.   But one of our new President’s Executive Orders, the federal hiring freeze, which garnered the least attention, impacted me the most.

The original plan, to return from Alaska, kick back for a couple of weeks, then return to Alaska to work with the VA, got derailed shortly after the inauguration. Especially because we have a family event in Pittsburgh the last weekend of April, the VA’s requested minimum 90 day commitment has lost its feasibility.

Emails to my planned employer have gone unanswered for a week and a half now, and it’s time for me to move on. Even if I know that winter in Alaska leaves most medical installations short-handed.

Working locum tenens taught me to embrace uncertainty. What happens in reality turns out better than what I had planned.

Back in 2010 I tried to book employment on my own, without an agency. I sent a mailing out to 25 nearby facilities, following up with 25 phone calls and 25 emails.  I got no response.  Since then all my work has been through agencies.  And I would have gone with an agency to the VA but for some shifts in budgets and Federal rules.

A good agency justifies their piece of the pie by value added services; a bad agency has difficulty justifying their existence.

(As a side note, my Canadian venture started with 5 months with an agent who didn’t work out. I struck off on my own, and 18 months later got a job offer.)

In the meantime I’ve been doing Continuing Medical Education with the American Board of Family Medicine, trying to keep me, and them, up to date; I got 56 hours that way. I’ve been doing some Canadian CME, too.  I read the journals that stacked up in our absence.  I go to the gym on alternate days.  I take a nap when I feel like it, several times a day.  I made 4 batches of moose jerky.

I had a novel in need of rewrites on my hard drive; I did 5 edits and submitted it to a publisher.

But I need to go back to work. I miss it.  I have an agent (more accurate than the commonly used term recruiter) looking at spots in Alaska, northeast Nebraska, and southwest Iowa.  Another agency offered a hospitalist spot in New Mexico.

Bethany and I go to movie matinees. We talk a lot about where we might go next.

 

 

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.

A single digit error explains low patient flow

July 27, 2016

I said to the front office clerk

I hope I’m not being a jerk

Someone who works in hive

Wrote  seven, not five.

Now will you please just send me more work?

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. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

After two months of no patient care I returned to work three days ago. Patient flow crept in the single digits daily.

Still I had bloggable moments.

We dealt with a cardiac arrest the first day. Doing CPR constitutes a valid workout, and people fatigue so quickly that the guidelines call for a change of personnel every 2 minutes.  My turn came, and the hospital CEO followed me.

For different people with different problems that day I advised drastic alcohol reduction, complete tobacco elimination, good hydration, sleep prioritization, regular exercise, and a return to counseling. I pointed out that marijuana aggravates anxiety, deepens depression, brings on paranoia, and sabotages life goals.

Yesterday we watched through my office window as the crane lowered a new installation, really a prefabricated building with very expensive equipment, into place. The machine, worth dozens of millions of dollars, came down slowly, guided by men in hard hats with ropes.  I recalled my days in construction, when I swept the concrete footing furiously just before the crane lowered the form.  I looked at the odd clods of dirt on the footing and shook my head.  The stucco wall now sits three feet outside my office window, completely obstructing the view, and reflecting the heat from the sun.  I’ve quipped it’s a monochrome mural by a noted abstract artist titled Beige Wall, and offered to forge a Salvador Dali signature on it.

I performed my version of a complete neurologic exam on 4 different patients yesterday; all completely normal. I deal with a lot of patients with headaches, migraines and others.

But I also took care of a very sick patient. At the end of the day, I ordered a lot of lab work, all of which got sent to a reference lab an hour away.  I left my phone number with the techs, telling them that they could text me results without violating HIPAA as long as they didn’t attach a patient name.  And I could do so safely because I only had one patient hospitalized.

Today the low patient flow continued. The new installation required lots of drilling through my office wall.  I fled the intolerable noise to chat with a colleague.  But I also passed a front office staffer at a critical time.  She asked me my UPIN.

Various entities have assigned me various unique identifying numbers, starting with my 9 digit Social Security number. The longest one, with 14 digits, comes from Canada. I gave her the 10 digit number, flippantly, ending with 365.  She frowned.  The one she had on file ended with 367.

That one digit error resulted in no insurance credentialing for 5 companies. The clinic administration worked hard much of the afternoon to try to set things right.

While the drilling in the wall continued.

I thought about the Bob Dylan song, Lily, Rosemary and the Jack of Hearts.

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.

 

On Chest Tubes and ATLS

November 15, 2015

I studied up for a test

That involved a tube in the chest

For the old and the young

When collapsed is the lung

That treatment, life-saving, is best. 

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 drove south to Kansas City for the Advanced Trauma Life Support (ATLS) course.

In medical school, I saw exactly one chest tube insertion, involving the “best chest surgeon in town” (in retrospect, either bipolar or alcoholic but more likely both).  I watched the surgeon make repeated jabs with a scalpel into the chest of an unanaesthetized late adolescent man who had come to philosophical terms with his upcoming death from cancer and just wanted to die comfortably. I observed the screaming and the torture for as long as I could.  When my vision contracted down to a tunnel, I knew I would faint, and rather than do so at the patient’s bedside, I forced one foot in front of another down the hall to the dictation desk behind the nurses’ station, laid down, and fainted.

The experience put me off chest tubes, but chest tubes can make the difference between life and death when a lung collapses (pneumothorax) or blood pools inside the chest on outside the lung (hemothorax).

The first time I did the ATLS course we used live, anesthetized dogs and cats to practice endotracheal tubes, venous cut downs, and chest tubes.  It bothered me then and it bothers me now that the animals did not survive our education, but the experience of the dying 18-year-old bothers me more.

I got out of the Emergency Room.  My certification lapsed, decades passed and the century turned before I needed that credential again, when my work in remote locations brought me to ER coverage.  In December of 2010 I took the ATLS again.  We used manikins for practice, not living animals.  Venous cut downs had almost disappeared.

I do not regret never having to use those skills.

Now that I stalk the locum tenens trail again, some facilities want the credential, and I discovered, to my chagrin, that mine lapsed a year ago.

Venous cut downs, the last ditch to get IV access, have disappeared in favor of a technique that bores into a long bone, called interosseous.  Endotracheal tubes continue.  The scopes still use incandescent light bulbs, having failed to progress to halogen, they may skip directly to LED but will more likely be replaced by the video Glidescope by the time I recertify next, in 4 years.

The chest tube practice manikins continue to improve, providing a closer simulation to a live human than a cat or dog ever could.

I hope I never have to use my skills.

If it’s not a problem, it’s not a problem

November 8, 2015

I couldn’t do any good with medication
I thought I would try education.
I said, “Now you’re full-grown
You can just leave it alone.
Avoid, if you can, operation.”

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 two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.
When I get permission to write about patients, I usually say I won’t mention age or gender, but I like to talk about diagnosis. For the first patient of Halloween, however, I switched. I requested and received permission to mention age and gender and only vaguely refer to the problem.
Just looking at the active 71-year-old gave the diagnosis. But the diagnosis didn’t compromise function, and fixing it would have led to months of recuperation. Doctors only have four things we can do, I said. We can medicate, operate, educate, and manipulate. And none of those will improve your function. And with surgery, we always have a chance of making you worse. If it’s not a problem, I said, it’s not a problem. And trying to fix it will take you out of work.
We had a good discussion on second-stage careers. We both face problems of trying to slow down but not wanting to stop. We both revel in the activity, challenge, and socialization of work. And we both face the challenge of limiting hours in the face of high demand for services. And we both sometimes over-commit.
I recounted my experiences with a patient at another clinic, a mason who worked well into his 90’s. When I knew him, his personal integrity brought such high quality to his craftsmanship that he could charge whatever he wanted for her services. But by then, he didn’t work for love of money. He picked his jobs by the size.
As the day wore on, respiratory infections dominated the diagnostic landscape, with skin problems coming in second. An x-ray showed a fracture, another didn’t. I took out ticks, whole and by the piece. I laughed out loud when a patient referred to a particular horse as a “tick magnet.”
With so much Lyme disease prevalent in the tick population, any engorged tick, or tick bite of unknown duration gets presumptive Lyme disease treatment.
At the end of the evening, I drove country roads back to the hotel, hyper-alert for deer going into rut. When I walked past the front desk, the clerk asked me if I were a doctor today. When I figured out he viewed my scrubs as a costume, I laughed. Yes, I said, I’m a doctor today, and I was a doctor yesterday. And I took chocolates from the bucket on the counter.

Back in Pennsylvania, Urgent Care and a Transformed EMR

November 6, 2015

It’s an updated, revised, EMR

In the last five years it’s come far

But down the wrong road

It’s as slow as a toad,

It can push a doc towards the bar.

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 two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I drove the large rental car away from the airport into the Pennsylvania countryside. A simple transposition of two numbers for my phone contact with the hospital led to confusion and tension.
I stopped into a UPS store. As I walked in, the clerk looked up and said, “Here for fingerprints?”
“How could you tell?” I asked.
“The piece of paper you’re carrying,” he answered.
The new inkless technology contrasted to my last fingerprinting 5 years ago in Barrow, Alaska; everything about the northernmost point in the US qualifies as a unique experience.
Finished with fingerprinting, I figured out the phone number, got ahold of my contact, and entered the right address into my GPS unit.
Fall colors dominated the forests, and cute furry animals like deer, possum, and raccoon littered the country roads with their lifeless bodies. A few cornfields retained a trace of green, but most stood dry and ready for the harvest. Huge round bales of hay lay scattered over alfalfa fields. It felt a lot like home in Iowa, but agriculture here has to deal with a more and steeper hills.
The GPS took me to an address having nothing but buccolic pastures. I followed the properly named road another mile and came to a new-loooking medical building.
The Urgent Care clinic has its own CT scanner and MRI machine, but rarely used for same day studies from Urgent Care. I had a good conversation with the doc there. He showed me around, praised the nursing staff I’d have the next day, and walked me through an electronic medical record system I’d worked with while in private practice.
But this version suffered from updates and looked nothing like what I remembered. It boasted spiffy colored graphics but shuffled and gimped like a zombie. I took notes, and, at the end, I drove back to a Chinese buffet, ate large, came back to the hotel, and slept hard.
The next day started off busy, and the EMR became even more truculent than I could have imagined. It suffers from a counter intuitive, chaotic layout. It runs slowly, with plenty of 15 second click-and-wait features.
With incomplete documents piled well into the double digits, I got a call from an ER doc who talked me through the trouble spots, and as the patient flow lightened, the annoying data entry sped up.
I finished my charting on time, leaving at 9:00PM sharp.
The stress of learning a new EMR system took a toll. I remembered back to the time when the Practice Formerly Known As MIne made the conversion from paper. The steep, six-month learning curve took me well outside my zone of comfort. Halfway through the process, I had a second glass of wine on Friday night while at supper with friends, and not before nor since has my wife has seen me consume alcohol under stress. She doesn’t remember it. I do. But I didn’t have a drink when I got back to the hotel. It would have ruined my sleep.

A sudden call, an urgent need, and a trip east.

November 5, 2015

The Canadian woman looked nice

I said the doctors here seem in a trice

She nodded and listened

While our system was dissened

The regulations come at a price.

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 two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

On Monday evening I got a call from a recruiter, naming a town where I’d worked that had a sudden need.

Despite the morbid curiosity, I decided I didn’t want to know the drama and irony that had led a colleague to back out of a commitment to work. I recognized the name of the town, I’d worked there before and I enjoyed it. I could walk from the hotel to the clinic.  I found a good hot breakfast in between.  But within a few hours, I realized that the town had the same name but the job pertained to a different clinic altogether. I said no.
My favorite recruiter asked me to please take the assignment. By way of loyalty borne of our good relationship, I accepted. A flurry of emails followed. I spent four hours filling out forms.
My five-year-old scanner printer stopped working. Which led to a great deal of frustration. Eventually, I photographed six documents with my cell phone and sent them via text.
The next morning found me on my way back to Pennsylvania. I had slept poorly, staying up late trying to get the paperwork taken care of.
At the airport in Chicago, i sat next to an attractive young woman. I glanced at her passport and said “Canadian, eh?” She chuckled. I told her that I was in the process of applying for a Canadian medical license, and she was surprised to learn about the frustrations of American doctors with ou current system. They boil down to four: electronic medical records, the meaningful use mandate, medical malpractice, and loss of autonomy.
She could not believe what I told her about the meaningful use mandate. Congress allocated funds for doctors to purchase electronic medical records, and gave them a small incentive to use them. Then, to provide proof that they were being used in a meaningful fashion, the Center for Medicare Services formulated meaningful use regulations, to be phased in over several years. Meeting them costs inordinate hours and has cut productivity of primary care doctors across the board by 25%.
And the regulations keep getting worse.
The conversation turned into a monologue and a rant, if not an outright Jeremiad. But she listened politely, and boarded her plane when called, I think with relief.

End of the Summer of Urgent Care

October 25, 2015

I could do as much as I’d dare

Sometimes not a moment to spare

From the first to the last,

It sure went by fast,

The summer I did Urgent Care.

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 two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

The vast majority of Family Practice involves delayed gratification or out-and-out frustration, the exceptional case, where the patient leaves better than when they walked in, comes as a treat.  When I owned my own private practice, I would have one or two a week.  Two would make a day, but a standard Urgent Care shift might include six.  Drain an abscess, stitch a laceration, remove a foreign body, clean out ear wax, splint a fracture, or take off a tick or any fraction thereof.

But I couldn’t give the anxious and depressed people my version of hit-and-run counselling.  Nor could I do much with the rather fascinating cases that required labs or sophisticated x-rays.  And if an x-ray showed a problem needing further imaging such as CT or MRI, I wouldn’t be part of the resolution.

I sent so many patients out by ambulance for chest pain that I can write about the aggregate without revealing any unique patient information, but I can say that people mainly concerned with chest pain shouldn’t come to Urgent Care.  I can say the same of the people who have the worst headache of their lives, severe abdominal pain, or anything problem related to pregnancy.  I won’t know what happened to those patients, nor the final diagnosis.

I saw very unusual x-rays and physical findings, but Urgent Care by its nature doesn’t involve follow-up, and I’ve resigned myself to not knowing.

When I took care of a person with a substance abuse problem, I had to make do with the briefest of interventions, but I suspect I did as much good, if not more, as I did in those cases where I had 45 minutes to spend.

I cared for 47 patients over the course of 12 hours my last day (this go round) in Urgent Care. I sent for the ambulance 3 times, I urged 4 more to the ER as soon as they could get there.  Out of 4 x-rays, 2 showed fractures.  For every patient for whom I prescribed antibiotics, I advised 4 that antibiotics would probably do more harm than good.  This late in the year I diagnosed poison ivy 4 times, with reactions much lighter than those I saw back in June.

I washed my hands or used alcohol based hand rub twice, minimum, for each of those patients, and I don’t anticipate the skin on my hands recovering for a week.

With that kind of patient flow I didn’t get a chance to talk to people about their lives.  I didn’t get to the fine points of social context leading to disease.  I missed quizzing people about the details of their occupations and hobbies, and learning about the wider world from the contact.

So I found the summer of Urgent Care gratifying but not satisfying.  Long, hot days have passed and the leaves are turning.  One morning I had to scrape frost from the windshield.  The action and immediate gratification might bring me back but for the time being I’ll work on something else.