Archive for the ‘Pennsylvania’ Category

Gandhi, the Whiskey Rebellion, and Obamacare

November 22, 2015

The farmers were put to the test

By the Feds, who thought they knew best

But the solution was risky

For those who made whiskey

When they expanded off to the west. 

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.

This summer I worked in Pennsylvania in the area of the Whiskey Rebellion.  I took the time to read the Wikipedia article.

My high school American History course treated the Whiskey Rebellion as a joke, taking about 3 paragraphs, alleging that the disturbance ended with not a shot fired.

The Articles of Confederation gave the country a weak central government, and the new nation foundered with poor law enforcement and inadequate revenues.  Native Americans increased violence on the borders, perceiving, understandably, that the invading Europeans (and unwitting Africans) lacked effective military.  Thus the country dispensed with the Articles of Confederation and adopted the Constitution.  And Congress quickly passed a tax on whiskey.

The tax imposed a disproportionate burden on small producers, located at the time mostly in the rural and western areas.  The big distillers supported it.

In Western Pennsylvania the small distillers held rallies and staged marches, and discussed long and hard whether to use violence.  They tarred and feathered some tax collectors, and besieged others with gunfire and loss of human life, mostly on the part of the rebels.  Eventually, George Washington himself led a force of 5,000 Federal troops to Pittsburgh, and the insurrection melted.  Those soldiers never fired a shot.

At the end the Federal Government had enforced laws not only for taxing whiskey but also for conscripting troops.

The Whiskey Rebels either quit distilling, moved, or paid taxes.

(As a sidelight, the failure of the Whiskey Rebellion jump started westward expansion, when the small distillers moved outside the US, illegally, into Indian Territory, alcohol softening up the resistance of the Natives.)

But the distillers in Kentucky didn’t protest or march.  They just kept on distilling.  I suspect that threats of violence or bribes resulted in the Feds having literally no tax collectors for the state.  And the moonshiners still conduct their business, quietly and profitably.

The Affordable Care Act (Obamacare) effectively hijacked the US medical system, and things have gotten very bad for doctors.  Any doctor who participates with insurance or Medicare/Medicaid spends an inordinate amount of time on clerical duties with no improvement in patient care.  We have four choices:  comply, move, quit, or stop taking insurance.  I hear repeated calls from the doctors, up in arms, that we need effective leadership.  And I hear lots of whining from doctors literally counting the days to retirement.

I look at Gandhi’s civil disobedience and at the Whiskey Rebellion and at the ACA and I think that the docs have put themselves down the wrong road.  We need to stop clicking boxes and take care of patients.  If enforcement becomes impossible, we could win.

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Finding and losing the rhythm

September 16, 2015

Air conditioning sure kept us cold

While outside the hottest weeks rolled

The corn grew so tall

We’re coming up on the fall

But I’ve put the rhythm on hold

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania, where I’m working for an Urgent Care company. Any patient information has been included with permission.

This phase of my career has fallen into a rhythm.   Two weeks in Pennsylvania followed by two weeks at home.  Packing now takes 20 minutes, unpacking, whether at home or at the hotel takes 5.  Leaving Pennsylvania comes on the heels of a long day at the end of a 48 hour work week.

I try to sleep late the departure morning, I rarely stay in bed past 7:30.  Then we do breakfast, a drive of an hour or two, fueling at the Sunoco, dropping the rental car, shedding boots for security, and the wait in the boarding lounge.

We know our way around the airport in Pittsburgh.  We know when to stop trusting the GPS, pull over and get out the map.

We have learned the relevant sections of Chicago O’Hare, and have gotten past that one section of bad signage.

If we arrive in Iowa in the daylight, we marvel at the growth of the corn and soybeans, now, respectively 10 feet and chest high.

As soon as we walk in the door at home, we unpack and attack the mail.  With the exception of three magazines and four professional journals, I put everything exclusively addressed to me in the recycling.   If we’ve made it home in the daylight, we pick tomatoes and green chiles from the garden.  I roast the chiles over charcoal.  Bethany checks the voice mail on our machine.

At the same time I have found the rhythm between home and Pennsylvania I have lost the rhythm of the week.  The predictable patient flow pattern of the week in private practice, or even in the outpatient section of Nome, just doesn’t happen in Urgent care.  It doesn’t help that I rarely start my work week on Monday and I never work Friday.

By the same token the shift in climate inherent in jet travel shattered the flow of the season.  I catch the progress of the corn and soybeans between the airport and home, but two-week gaps account for a lot of change.

Working 12 to 14 hours a day with enthusiastic air conditioning removed most of the sense of summer.

In the meantime, work continues on my Canadian license, but very slowly.  I finally got the College of Physicians and Surgeons to accept my $600.  My residency program faxed my records but they haven’t made it to the right person’s desk.

Kung Pao unrushed

September 10, 2015

A leisurely lunch can’t be beat
A time to savor, to rest, and to eat
With minutes to burn
And a good chance to learn
And send patients, fast, down the street.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania, where I’m working for an Urgent Care company. Any patient information has been included with permission.

The Urgent Care concern I work for has many locations, and each has a unique flavor. The spot I worked at last week and most of this week, for example, maintains a reasonable patient flow and rarely gets too busy; my experience over the holiday weekend qualifies as the exception. I had 40 hours in by the time I walked out Tuesday night.

Today I worked at a different site famous for its triple digit days.  Last month I had intense experiences here, which, all in all, I would prefer not to repeat.  I arrived with my metaphorical flak jacket on.

To everyone’s surprise, light patient flow graced the morning, and after the first four hours we all expressed disbelief. But a mood of tension enveloped us, in anticipation of really bad stuff.

At 11:00 I placed an order for Chinese food delivery; it arrived at noon and I got to eat it hot.

More than just food, lunch needs to be a time when the stress ceases.  In the last 35 years I bolted the vast majority of my mid-day nutrition, rarely tasting the food and certainly not resting.  Today I ate egg drop soup leisurely, then turned my fork on the Kung Pao chicken.

Things slowed down after lunch but the tension didn’t stop. I caught up on my email, finding the latest snag in my quest for a Canadian license.  My Community Health Center asked me to cover Christmas.

The number of people who came in with colds but who didn’t want antibiotics surprised and pleased me.

I saw a person with alopecia areata, a patchy loss of hair, usually on the scalp. It can happen anywhere on the body, but people notice it most where they have the most hair. When it regrows, which it does most of the time, the result is a white patch. I’ve known a handful of people with white eyelashes on one side. Today I had the time to go look it up; I hadn’t seen a case this century. In the Information Age, I could find out how little of what I remembered has stayed true. Topical steroid treatment, once controversial but now the standard of care, combines with minoxidil, the hair restoring agent now available over the counter.

Business picked up shortly after supper while rain beat heavily on the roof.  I remarked to several patients that I felt flattered by the confidence they showed, but, under the circumstances, the diagnostic capabilities of Urgent Care don’t measure up to those of an ER.  More than one needed CT scanning, ultrasound, and extensive diagnostic blood work.

Some problems don’t belong in Urgent Care at all.  People with chest pain, vigorous bleeding, major trauma, shortness of breath, and major neurologic changes, for example, belong in the Emergency Room (multiple examples of each have come my way in the last three months).  Yet I understand the tendency to come to us because of the horrendous wait elsewhere.  Yesterday, when I called ahead to the hospital regarding a life-threatening case, I learned that 94 people sat stacked up in their Urgent Care section.

I miss not learning the follow-up on the cases I sent out.  We can’t learn from experience without feedback.

Pie, ice cream, and click-and-wait

September 7, 2015

Oh no, please.  Not again

The problems with ICD-10

It makes us all late,

The darned click-and-wait

Why can’t we go back to the pen?

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I have just finished a 14 hour day.

I haven’t worked many Labor Days, so I have little basis for comparison.  But the day started slow, I didn’t see any patients till almost 9:00AM.

The crew brought food to share.  Light-hearted banter echoed through the clinic.  I read my email, went to a doctors’ social media site, and read Wikipedia about things medical and literary.

I introduced the PA to the wonders of Zanfel, an over-the-counter agent that can take the poison ivy resin out of the skin.

Bethany brought ice cream, pie, and a rotisserie chicken over at 11:00AM.  I didn’t want to jump the gun on lunch.  But a few patients trickled in and about 1:00 I ate.  I texted Bethany to come over in the early afternoon.  The PA left at 2:00PM.

The pace picked up to reasonable and stayed there till about 5:30, when the patients started signing in at the rate of 6 per hour, and it got really hectic.  Twelve patients signed in during the last hour.

A distressing number of x-rays in Urgent Care show fractures, certainly a better yield than when I worked in private practice.  We see more abnormal chest x-rays as well,  but most of the problems related to asthma or acute infection.

The poison ivy patients made a resurgence, probably because overall high numbers.  Skin and soft tissue infections remain important.

Lyme disease stays a concern.  Twenty percent of the ticks carry the disease.  Any tick on long enough to become engorged, or  present for at 24 hours demands presumptive treatment with a very short course of antibiotics (200 mg single dose of doxycycline).  I have seen an inordinate number of the “bull’s-eye rash” (erythema chronica migrans) of early Lyme.

I also see too many people, convinced they have chronic Lyme, on long courses of dangerous antibiotics.  And anyone with any heart problem at all gets a test for Lyme.

At the end, with incomplete documentation stacking well into the double digits, despite fatigue. I did OK with the challenging patients.  I kept my cool saying “no” to inappropriate medication requests, I maintained patience with difficult children.  All in all, I did well with the people.

But last week’s shift from ICD-9 to ICD-10, intended to bring more specificity to the diagnostic process, has not settled well.  So, for example, for a foreign body I can easily specify which side and whether it’s the first or subsequent visit, but it took me 10 minutes to specify the correct organ afflicted.

I did not do well with the click-and-wait problems.

I finished with the last patient just before 9:00PM, and started on my 14 unfinished records.  The staff left.  While the cleaning crew went about their duties I sat in the quiet and relived the experiences.  I put down accurate descriptions of wounds, x-rays, and histories.  But I didn’t comment on the human cost of the disease, or what the injury meant to the patient.  Somewhere during the day, the headache and gut discomfort that followed me since Saturday, faded into the business.

When Bethany came to pick me up, in the warm late-summer darkness, I was pretty wired.

On seasonality of medical care

September 6, 2015

Here’s a thing I have come to know

It’s September, before the first snow

There must be a reason

For the pace of the season

For the flow of the woe to be slow.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

In the days when I owned part of a clinic, we noted a definitely seasonality.  Cold and strep season started up as the weather chilled, six weeks after school started.  That business increased at Thanksgiving, with a big jump after Christmas.  Influenza generally provided a lot of work till spring, when the athletic injuries started up and would last most of the summer.  School physical season would start about July and ran through August..

But things slowed down in September.  Warm weather, open houses, outdoor activities, and sunshine discourage the spread of respiratory infections.

For years I worked long hours in the summer while my partners vacationed, but I went on hunting trips during the slow business month.

People don’t come in at nearly as brisk a pace now, as summer slows into September.  The school sports physical season has almost finished.  We see a good number of those with sore throats, but the people with “summer colds” (really allergies) have diminished in number.  Folks suffering from poison ivy, half my business in June and July, now show up about once a day, and not nearly as severe as before.

I didn’t have a chance to care for a patient till after 9:30 this morning.  We got in a good number of people needing drug screens for their employment.

The memorable patients today (more than one) had heart problems, thankfully, not requiring ambulance transport.  I explained several times that the way a person’s hand describes the pain provides a valuable diagnostic clue.  The open hand next to the breast bone more often describes heartburn or anxiety, but the closed fist or clawed fingers usually describes blocked arteries.

But two-thirds of the electrocardiograms told alarming stories of drama and irony in squiggling lines.  For all three patients I made calls to facilities with expertise and options outside our Urgent Care scope of practice.

In the middle of the day, with plenty of time permitting, I took a chair out the back door and ate lunch al fresco.

Through the day I kept wondering when I’d see something I’d never seen before.  Because it happens every time I see patients.  Seven patients checked in after 7:35PM.  Closing time came and went.  Staff, understandably, wanted to go home.The PA and I slogged our way through.

Then, the very last patient had a physiologically inexplicable finding.  The PA had never seen anything like it, either.

Two cups of coffee after a bird strike.

September 2, 2015

A bird sure made our plane late

We missed by a hair at the gate

So a bit of caffeine

Kept my wit keen

With a steady patient flow rate.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

The smallest bird striking the largest commercial aircraft in the US in the 21st century demands an airframe inspection.  The regional jet coming into Sioux City ruined the day of a dove.  And so we sat in the departure lounge for a couple of hours till the inspection and the inevitable paperwork.

In medicine, the documentation takes as long as the visit, and I would imagine in aviation it takes longer.  I napped and I read.

Late to leave, late to arrive, we got to Gate H1 in Chicago O’Hare just after the flight closed.  The gate agent took care of the rebooking cheerfully and professionally.  He gave us meal vouchers and better seats.  We strolled the airport for a while, I got a torta and guacamole.  We settled down in the seats designed for discomfort.  I napped and I read some more.  We took off on time and got into Pittsburgh just past midnight.

I had slept much of the day at that point.  Connie, the GPS, took us on slow back roads that would enhance a leisurely Sunday afternoon, but doubled the drive time.  We wasted no time at check in but didn’t roll into bed till 2:00AM.

I had not one but two cups of coffee with breakfast.

It doesn’t sound like much but, outside of chocolate, my body doesn’t see much caffeine.  Thus a little goes a long ways.

I nearly fell asleep before the first patient arrived at 9:30.  After that a steady, reasonable pace kept me awake and engaged and despite my initial dread I found myself grinning in the afternoon.  The PA arrived at 2:00, and the reasonable pace continued.  We took care of 48 patients in the 12 hours.  I got to speak Spanish with 2 (though both spoke English well).

This late in the summer, poison ivy continues to bring misery to multiple patients per day.

Sometimes patients with chronic pain ask for opiates, drugs in the same class as morphine.  But as time has gone on we’ve found that while such medications can ease pain in the short-term, in the long run they fail to relieve pain and they ruin functionality.  Frequently the patient will say in one breath that they need more of a drug that doesn’t work.

I wrote a prescription for a 5 day supply of hydrocodone for a person with a broken bone.  I hadn’t needed my DEA number for more than six weeks.

I give a lot of warmth and understanding to the people who have chronic pain at the same time I explain why opiates are a bad idea.  I print off a copy of my post, https://walkaboutdoc.wordpress.com/2012/12/09/pills-and-skills-you-need-a-tool-set-to-deal-with-chronic-pain-caution-longer-than-average/.  I get mixed reactions.  Those serious about pain management read it carefully, those serious about just getting the drugs pitch a fit and stomp out.  And I can’t predict who will do what before hand.

I left the clinic at 8:37, ready for bed.

If you use caffeine rarely, it will serve you as an ally.  If you use it habitually you will be its slave.

I estimate my exercise output and my caloric intake badly

August 27, 2015

How much was it I ate?
I don’t know, but I can estimate
I know that I guessed
And it wasn’t the best
But there’s no denying the weight.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

Most Americans struggle with their weight because human beings are lousy estimators. We badly estimate how much exercise we got and we badly estimate how many calories we have in front of us, and our waist lines slowly expand.
Working Urgent Care, I can eat a decent breakfast before work. I don’t take a formal lunch or dinner break. Sometimes I get lunch, and sometimes I don’t. I will, as instructed, eat enough to keep making good decisions, which generally means stepping into the break room in the midafternoon and wolfing down some provided snacks (I prefer Goldfish and peanuts).I try not to eat supper, because, like the majority of Americans, I struggle with my weight. Mostly, I fail, and I end up eating something when I get back to the hotel. I try to keep it light. I don’t always succeed.
When I used to work 12 and 14 hour days in private practice, I could exercise after work because my day started at 5:15AM, but the 8:00 to 8:00 schedule precludes exercise late or early without significant loss of sleep.
Wednesday, when my work week finished, I ate supper, and next morning ate an enormous breakfast. The trip home met with delays and cancellations, and the airline provided us with meal vouchers. Bethany prefers to travel hungry, but with 6 extra hours at Chicago O’Hare, I used all $24 to buy a mushroom torta, chips, and guacamole. I ate with guilt, aware I’d missed a lot of gym sessions and I hadn’t missed enough meals. Which didn’t keep me from snacking on chocolate almonds while the next plane boarded late.
One of our friends drove down from Sioux City to Omaha to pick us up. We drove back in the dark, arriving home to face two weeks of mail, neatly laid out on our kitchen table.
The next morning I gritted my teeth before I got onto the scale.
To my surprise, I’d lost 4 pounds in the two weeks we’d been away.
I didn’t snack as much as I thought. But I also have to figure that I got more exercise in the course of a day’s work than I’d realized. A pedometer would give solid numbers.
If you estimate well, you can generally find work, well, as an estimator. My track record on estimation, poor at best, keeps me out of that line of work. Which means I’m a lousy estimator.
Like most human beings.

Trade offs in Urgent Care

August 11, 2015

I enjoy my Urgent Care job
The patients come by the mob
But sometimes it’s our fate
We’re not done, but it’s late,
The rush just makes the staff sob.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I enjoy my current gig for an Urgent Care facility in suburban Pennsylvania.

My nominal work hours run from 8:00AM to 8:00PM. I go late on average one night out of three. Patients generally come in with problems of short duration and intense acuity. Most have a primary care provider who can’t see them in less than 3 days. Because management has developed a patient-centered approach, I do little redundant clerical work and thus I can spend a lot more time concentrating on patient care.

So far this week slow patient flow in the morning has given way to a brisk pace in the afternoon. Staff morale stays high, the big gripe comes against the rush of patients that starts after 7:00PM (about half the time). So tension builds on quiet nights as the clock ticks out the last half hour.

Poison ivy made up half the business back in June, but is now decreasing in frequency and severity. I have sewn up a lot of finger and hand lacerations. Two or three times a day we have the joy of curing the patient before they leave, mostly by taking out ear wax; but we also drain an average of one abscess a day. A majority of the x-rays I order show fractures.

People around here like to vacation at the beach, mostly New Jersey,Virginia and the Carolinas. We get a significant number of patients with swimmer’s ear and urinary tract infections related to the travel and swimming. And also the worried well who don’t want to be sick while on vacation.

August brings in the sports physical crowd. Basically healthy, the rare surprise disqualifications justify the activity.

Then, sometimes, with such a high patient volume (I consider 30 in a 12-hour shift light), serious illness demands an ambulance or an injection. Twice so far today I’ve advised patients to go directly to ER.

Earlier this week I helped wheel a patient into her waiting vehicle. I enjoyed breathing the warm summer air and smelling growing vegetation and seeing the summer thunderheads building in the north.

Occasionally a physical finding I’ve never before seen heralds a puzzle, and I refer to a specialist.

We refer all broken bones to orthopedists.

Urgent Care has its share of joys but so much of the fun comes from the fast pace and the easy-to-solve problems that the awe and mystery of unraveling complex disease one lab result at a time gets lost. An upscale, insured population obviates the opportunity to serve the under-served. And I miss speaking Spanish.

Life always involves tradeoffs.

9% Grade: New Bethlehem to Kittaning

August 9, 2015

Many the story I’ve told,
About the horrible hills I once rode,
I know where I’ve been,
To ride them again
Would ignore my life’s lesson code.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I finished my first undergraduate career in 1972 with no plans for the future aside from bicycling back from New Haven, Connecticut home to Denver, Colorado. I went with Al, a roommate for 2 years.

I sent my winter clothing, bedding, and books parcel post. I looked at everything else I owned and divided into two piles: one to take with me and one to throw away.

The trip changed my life. Four years later I sat in a small room in East Lansing, Michigan, at my fifth and last medical school interview. The first four had gone poorly and I saw my last opportunity at my life’s goal hanging in the balance. In desperation, I spoke from my heart on what I learned that summer about the rhythms of the earth from lessons in bike repair, camping, weather, traffic, and minimalism. That interview ended up a fantastic success, and I got a place at Michigan State.

I started the trip with 32 pounds of gear and finished trip with 26; the bicycle weighed 34 pounds and did not change materially. Bicycles became embedded in my life that summer; I bought Bethany a tandem instead of an engagement ring.

In the summer of 1975 I rode from Denver to San Diego in 11 days, and over the years I commuted so many miles that I could look at a derraileur and say, from experience, that it would only last for about 5,000 miles.

The worst hills I could remember came that first long trip, in the 19 mile stretch from New Bethlehem to Kittaning, on Route 28 coming into Pittsburgh from the north. It took us three hours, and we didn’t know if we could make it the rest of the way to town (we did).

But sometimes a forty-year lens magnifies misery. I wondered if that stretch really had that many steep hills; on my day off I decided to drive it in the rental car.

Coming north from Pittsburgh, I recounted to Bethany the horrors of that trip, and wondered aloud if it really had been that bad.

Yes, it had been, long steep grades separated by no more than 50 yards of flat. One sign, coming into New Bethlehem, that we wouldn’t have seen from a bicycle headed south, said “9% GRADE TRUCKS USE LOW GEAR.”

Nine percent?

NINE PERCENT??!! A railroad can’t climb anything steeper than 6%; neither Casper Mountain in Wyoming nor Mount Taylor in New Mexico came close. And this thing went on for a couple of miles, and dropped almost as badly on the other side.

With such focus on steepness, I failed to remember the narrow and sometimes non-existent shoulder.

I thought back to other superlatively negative experiences: high school, the worst night on call (38 hours with one 45 minutes break), the heaviest clinic day (63 patients in 6 1/2 hours), the worst Electronic Medical Record (Centricity).

I accept my memories as accurate, I don’t have to do those again.

Iowa house calls, back to Pennsylvania

August 7, 2015

For a house call I went to a store
Then expected one or two more
To come to my house
So I said to my spouse,
They’ll come in through the front door.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

While home in Iowa last week I made a couple of house calls.

One patient owns a business I frequent, and had called me when we were both on the way back to Iowa. Our professional relationship dates back well into the last century. We have watched each other progress professionally and socially. He gave me the go ahead to write the entire visit in this venue as a record, but, for the same reason I conducted the interview on the deserted freight dock and the exam in the store’s quietest corner, I didn’t. At the end, he personally helped me with my selections and would not accept money for the transaction; nor would I accept payment from him.

Another friend has had a problem building for months; we agreed on the next step: the specialist.

The garden has come in, and Bethany and I snacked on the first of the tomatoes, cucumbers, and green chiles; We invited company for supper on Friday. For a side dish, I cut sweet corn from the cob, added red onion, roasted green chiles, lime juice, and olive oil.

I took call for my Community Health Center the weekend. One patient discharged from peds on Saturday and one admitted on Sunday,far cry from a census demanding two docs to round both mornings, with one up all night to take admits and calls.

Tuesday found us back in Pennsylvania, at an Urgent Care, working 12 hour days, but this time we can walk from the hotel to the clinic. I like the medical record system. I can whiz through documentation for respiratory problems, but skin and musculo-skeletal problems need more narrative because no two are the same. A disproportionate number of patients come in with poison ivy.

Urgent Care, by definition, doesn’t include ailments that need follow-up or CT scans. I sent a number of patients each with suspected heart attacks, blood clots, or kidney stones to the local ER. People with bipolar disease tend to have very real, severe physical problems. I can treat those injuries, but getting at the root cause falls outside my scope of practice.

To those patients who come in, for example, with weight loss (now into the double digits working for this client) I say, “This is not normal, but there is a limit to what can be known an hour, and there is a limit to the lab we can run in Urgent Care. You need a primary care provider, and here is a list of labs that he or she might run.”

Nor can I effectively treat rheumatologic problems, but rheumatologic patients come to see me nonetheless. From time to time I run into people on Enbrel, and then we generally have a happy support group meeting. We talk about how the drug changed our lives; how, coming out of the pain we could engage emotionally with our families; and about how, outside the pain relief, we just feel better; (I feel better now than I did at age 18).

If I talk to a back pain patient on opiates, I tell them how the medication inhibits their own ability to make endorphins and perceive endorphins. Some express shock and amazement, and some just want me to prescribe the Norco, because “it’s the only thing that works.”