Archive for the ‘Slowing down’ Category

The difference between a horse and a mule

August 23, 2012

It’s unnecessary to that much force

To run to the ground a great horse.

So don’t be a fool,

You can stop, like a mule

If your motives come from the source.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Even doctors have to have doctors.

I confirmed my appointment with a subspecialist today at 12:45, and I turned to Bethany.  “He works through his lunch hour,” I said.  “Should I bring him a sandwich or something?”

“I don’t know,” she said, “Are you sure he doesn’t take a late lunch?”

“Yeah, his nurse said he was working through his lunch hour.”

“You can if you want.  But is he working for someone else?”

“No,” I said, “He owns his practice.”

“Well, when you were an owner, you did the same thing.”

Of course she was right.  “That’s the difference between a horse and a mule,” I said.

A horse has a passion to run, I explained, and riding a good horse hard ranks among the great experiences of life.  A mule has none of the fire of a horse, and the best gallop of the best mule deserves the word lackluster; the words plod and mule go well together.  Yet most riders can get a horse to run so far and so fast that the horse dies, hence our term, “ran it into the ground.”  An overloaded mule cannot be induced to move at all.

Give a horse morphine and the horse will run, give the horse an adequate amount of morphine and he’ll run himself to death even without a rider.

I approach analogies between humans and animals with caution.  But making any person, and particularly a doctor, their own boss looks a lot like giving morphine to a horse.  They don’t take enough vacation, they work very long, very productive hours, and they tend to burn out.

I wish going onto salary had made me more like a mule.  As it is, my drive to work destructively long hours has nothing to do with the money but with the action of the job and my commitment to my colleagues.  I do not want to give up the drama and irony of the hospital work, nor the intellectual challenge of having to rub elbows with docs who know more than I do.  Nor do I want to stop being part of the team, going the extra mile to lighten the load of the doctor who comes after me.

The problem comes not from the outpatient hours, but from the people who get desperately ill after hours and on weekends, and from our booming expansion.  My first two weekend calls last year had a total hospital census in the single digits, but our practice now averages seven hospital admissions per twenty-four hours and our hospital census has gone as high as forty-two. 

Yet this last weekend deserves a delicious rating.  I started early, finished rounds in good time, lunched and napped and supped, getting into bed before eleven each night.  I’m running on the same relaxed euphoria that I did a year ago.

The real question is how hard I’ll let myself get worked.

Blog end: I’ve reintegrated

January 16, 2012

I had a great time, it’s a fact

My life had been so out of whack

I flew cross the sea

From Barrow to Leigh

Now I’m home and it’s good to be back.

I received an email from a doc who went walkabout to New Zealand for a good deal longer than I had, and asked me questions about my reintegration.  I asked for permission to post the original missive, but three weeks later haven’t heard back.

I replied: 

It’s interesting that you emailed me six months to the day after I started back into work here in the States, and if it’s OK with you I’ll use your email and this return as a post.

I’ve enjoyed reintegrating to US society and the medical care system.  I’m back doing hospital work, which, strangely, I really enjoy.   I know my consultants on a first-name basis and I like the camaraderie in the hospital.

It helps that I’m working for a Community Health Center.  For a lot of reasons, our patient population gets sicker earlier.  The pathology load weighs heavy on them.  At any one time, half of our twenty to thirty hospital patients also appear on the nephrologists’ list because of chronic renal failure and dialysis.  Usually we have three people in active DT’s and three others in liver failure. 

I have had to get used to the paranoid reality of defensive medicine.  Our patient population has made the transition easier because many have no money and no insurance and hence can’t pay for procedures that probably weren’t needed in the first place.

For those with insurance, I worry that I overuse medical technology.

Getting labs back the same day, like glycohemoglobin and TSH, makes patient management easier, as does having in-house x-ray.  

I liked MedTech32, the electronic medical record (EMR) system that makes documentation so easy throughout New Zealand, and the hardest part of coming home has been dealing with Centricity, whose software engineers remain isolated from any contact with this particular end user; for example, I have to click through five data fields to make a back to work/school slip and I have no way to fix it.  My productivity has gone way down; eleven patients in a morning or afternoon taxes my resources; not that I spend more time with each patient but I spend more time fighting the computer to enter data.  And about half the problems could be fixed easily.

I miss the way I always started on time in New Zealand because I brought my own patients back from the waiting room, and I miss the way the patients (mostly) respected my time.  In my current situation I limit the patients to three problems per visit.

Narcotics seeking remains a problem here as well as everywhere.  I’m building up a reputation in the street-drug community here, just like I did in the South Island, as parsimonious with opiates and benzodiazepines. 

Still, my practice swells with new patients every day.  I like pediatrics, and I find that a new practice attracts young people and young families, even with an old practitioner.

In the long run, most people either fit into the category of wanderers or homebodies, and I am definitely a homebody. 

But man, did I have a great time.

2011 in review

December 31, 2011

The stats can be more or few

Here is the year in review

Some of my readers

Worried about bleeders

But over all, quite a nice crew.

 

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

 

Here’s an excerpt:

The concert hall at the Syndey Opera House holds 2,700 people. This blog was viewed about 15,000 times in 2011. If it were a concert at Sydney Opera House, it would take about 6 sold-out performances for that many people to see it.

Click here to see the complete report.

Tomorrow I’m back on the job

June 19, 2011

Today I awoke with a jerk

Though free time can be quite a perk

     Away I did roam

     And now I’m back home

Tomorrow I start back to work.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  During my year-long sabbatical, while I danced back from the brink of burnout and my non-compete clause expired, I traveled, had adventures, and wrote.  Tomorrow I start regular work again at the Sioux City Community Health Center. 

When we left Sioux City for New Zealand we hadn’t cleared things up from our stay in Alaska.  In the process of packing, editing, and repacking, I left disordered mounds of clothes, crammed drawers, and messy floors. 

I forgot about them while we were gone.  We found the house orderly when we returned, but I keep coming across things that need revising, drawers that need setting in order, and things that need to get divested.  My long underwear alone I found in three different drawers and on two different horizontal surfaces.

I’ve been whittling away at my mail since we got back; I try to get rid of at least two magazines a day but the pile of unread journals remains daunting.

Jet lag has improved, and I slept through the night last night.  I still get sleepy most afternoons and the occasional morning but nap duration has returned to my previous 18 minute specials.

The fact that I start back to work tomorrow excites me at the same time it feels like I’ll be, well, working.  After all, from May 21, 2010 to June 20, 2011 it felt like vacation even when I spent sixty-three hours a week on the job.

Sleeping in our own bed ranks as a euphoric experience, and planting my garden marks a return to reveling in the sequence of seasons.  Abruptly changing from long, cool New Zealand nights to the long, hot humid Iowa days has jarred our systems.  It reminds why I spent last summer in Alaska.

I have returned refreshed and optimistic.  Even though I’ll go back to a job tomorrow I have set things up so I’ll have enough time to write, garden, exercise, play music, hunt, read recreationally, and breathe.

Contrasts strike me every hour of every day.  I drive on the right down broad lanes with quiet pavement.  Home smells like home, gas and food come cheap, Iowans weigh a lot more than Kiwis, haze hangs in the air.  When we play Scrabble we have dictionaries ready to hand.   We don’t struggle to understand the Kiwi accent.  We haven’t seen a single sheep since we arrived, and corn fields dominate the landscape. 

Underlying the upbeat mood of our homecoming runs the town’s worry about flood from the Missouri River.  The Dakota Dunes community, displaced from upscale homes between the Missouri and Big Sioux Rivers, has moved into Sioux City and snapped up real estate and rentals.  The water, high when we arrived, has continued to rise.  Interstate off ramps have morphed into boat ramps. 

We have all considered worse case scenarios, where abrupt snow melt and heavy rains trigger domino-like dam failures all the way down the Missouri and the Fort Calhoun nuclear plant, sixty miles south, goes critical.  Yet the town keeps an optimistic mood while we fill sandbags and take the weather seriously.

When is a trip home like a spider? When it has eight legs.

June 17, 2011

A limerick isn’t a poem

A blog sure isn’t a tome

     This thing they call jet lag

     Comes out to big drag

But happiness is being back home.

Synopsis:  I’m a family practitioner from Sioux City, Iowa. I took a sabbatical to dance back from the brink of burnout.  While my one-year non-compete clause ticked away, I worked in Alaska, Iowa, Nebraska, and Alaska.  I had a lot of adventures working in out-of-the-way places.  Now I’m back home, getting ready to start my new job.

When is a trip home like a spider?  When it has eight legs. 

Our trip home lasted thirty-eight hours and left us with the worst jet lag we’ve ever had.  We slept badly even before boarding the plane in Dunedin.  From Dunedin to Christchurch to Wellington to Auckland (thirteen hours) we might have napped on the plane, but we didn’t get restorative sleep. 

Turbulence, related to the recent Chilean volcanoes, dominated the twelve hours spent flying to Los Angeles.  I ignored the bucking airplane and watched three movies, and didn’t sleep. 

By the time we deplaned in Phoenix’s late afternoon the temperature exceeded anything we’d experienced in New Zealand. 

Omaha at midnight had darkness and thick, sweet summer air.  Long detours necessitated by the Missouri River flooding added an extra forty-five minutes to the drive home.  By the time we actually walked into the house the clock came close to 3:00 AM.  Our trip had lasted thirty-eight hours, if you don’t count the travel from Bluff to Dunedin. 

Jet lag hit us hard in LA and didn’t get better as we progressed.  Both aware that neither of us could process information well, we showed immense patience with each other; I doubt either of us could have negotiated the trip home alone.

We suffer not just from the time difference but also from the abrupt change of season.  We departed for New Zealand near the equinox, when day and night all over the planet approached twelve hours, but we returned home just before the solstice.  Dunedin’s shortest day would coincide with Sioux City’s shortest night a mere eight days after we landed.

Our body clocks have been thrown into chaos.  I have been on the ground for three days and only now am I starting to write again.  I awaken at about 4:00AM and crash hard at one in the afternoon.

Of course I went to my new work place less than twenty-four hours after I arrived; I needed to discuss my upcoming schedule.

Unlike a lot of the family practitioners these days I enjoy hospital work, rubbing elbows with the specialists and providing continuity of care.  My new routine will start with hospital rounds for the group Monday, Tuesday, and Wednesday.  If things go according to plan, after lunch those days I’ll do clinic, and I’ll have an evening clinic on Mondays.   Those twenty-eight hours, combined with my share of a one-in-eight call rotation, add up to 45.7 average hours per week, which, for a doctor, means part-time work.

While I’m away, tornados and floods hit close to home

May 30, 2011

Out here I still have to worry

About my friends on the River Missouri

     In the spring flowers bud

     But the rivers run flood

And they might have to leave in a hurry.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and working the last half of a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

When I left Sioux City a year ago (to the day) and flew to Barrow on the shore of the Arctic Ocean, I lost my concerns about the Practice Formerly Known As Mine.  I took a vacation from my worries. 

People on the North Slope might know about world events, but hold more interest in the whale harvest, Nalukaataaq, and the Fourth of July Parade.  Barrow ceased being the middle of nowhere and became, in my mind, the center of the universe.

I have never been able to control world events, and during my travels I started to take more interest in the happenings on the ground around me. 

The big September temblor in Christchurch made headlines last year at a time when I didn’t have New Zealand firmly on my radar, and I noted it only in passing.  I heard about the big quake in February, when I returned to Barrow, and took a ribbing from the hospital staff about my goals.  At the time, I didn’t know Christchurch’s status as the largest city on the South Island, nor did I appreciate the difference between the two islands.

American news interests me less now that I’m in New Zealand, and I’ve taken a growing interest in Kiwi doings, following, for example, the schism in the Maori Party that formed the Mana Party and the ongoing problem with the Christchurch rebuild.

I still take an eight-hour break from worrying every night (except call) because my cell phone doesn’t work reliably. 

Not that I’ve ever been able to solve world problems but when I measure my distance from hotspots in thousands of miles, I give them less energy.

Some American news can’t be ignored; the Joplin tornado story rated front page status here.  That twister struck literally too close to home.  I shake my head and I think about the Midwest.  Tornado season hasn’t come close to peaking yet.   This summer could set some terrible records.

Today I heard about rising waters on the Missouri River, threatening an upscale town close to my house.  I have good friends living there who, under orders from the governor, have moved out their personal belongings and sandbagged their homes, staying alert for an evacuation order. 

Via the Internet we have offered our Midwest home to those who need it.   There’s a big difference between problems you can do something about and problems you can’t.

Planning too much versus not planning: the optimum dances.

May 29, 2011

In the past I’ve done what I can

For the future, just making a scan

     I took a chance on a blunder

     To re-ignite wonder

Sometimes I still make a plan.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and working the last half of a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

Bethany and I taught and participated in a diet/exercise program, Ultimate Bodyshaping Challenge (UBC) for five years.  One of its guiding principles, “when you fail to plan you plan to fail,” rings true in a lot of human endeavors.

The opposite slogan, “just do it,” carries the message of spontaneity and adventure.

I have learned that both approaches carry validity.  I don’t know if I want to strike a balance or resonate between the two principles.

For years I did an inhuman amount of work, going top speed at peak efficiency sixteen hours a day.  I reached that level of productivity by knowing each step of the day before I got out of bed.  Such a system gets a lot done but lacks resilience and strains the psyche.

I faced a tradeoff: efficiency vs flexibility.  And while life is full of tradeoffs, I had gotten a particular mental set of what life felt like.

In the last year I’ve learned that slowing down 20% did away with half the stress (check my posts from a year ago in Barrow).  I also found out that I fail to plan a day and still enjoy it.

Bethany and I, with another physician/teacher couple, Cheryl and Larry, took an excursion via train from Christchurch to Greymouth, on the west coast of the South Island.  We arrived with few plans and no expectations.  The hotel we’d booked turned out to be 3 kilometers (1.8 miles) from the railway station.  We took a taxi out, dropped our bags, and walked into town on the beach.

I’d never been close to the Tasman Sea before.  I hadn’t read anything on the net, I had no expectations.  I watched the violent surf crashing a dozen meters from where I stood at the low tide line.  Rounded rocks, grey smooth granite and white and pink marble, dotted the light grey sand.

If we plan everything we do, and if everything goes according to plan, the world loses its surprise, and, with it, its wonder.  Encountering new things involves risk, but fear and risk don’t keep us stuck in a rut as much the mental set that tells us what life should be.

Yet without a plan I wouldn’t have gotten to the beach.

Where do we find the optimum between planning and spontaneity?  If we can’t define an end point, does an optimum exist? 

Or does the optimum shift and dance away, depending on our phase of life?

Retrospective: distilled aphorisms from last summer’s posts

May 22, 2011

It’s been now a year and a day

Since I left near the end of last May

     I’ve bettered my writing

     I’ve weathered weird lighting

And I’m not doing this for the pay.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and working the last half of a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

My non-compete clause expired yesterday; I went over my posts from that time, and found the following pieces of truth:

One cannot go to discover new adventures without leaving home; mobility must be weighed against cost.

Life is full of tradeoffs.

Anyone who asks for medical care in the hallway deserves what they get.

Little is certain in life, especially when it comes to the future.

If “call” means twelve hours, the term carries fewer negative connotations than when it means seventy-two hours.

Two doctors who talk to each other will consistently give better medical care than one doctor, no matter how brilliant, who doesn’t converse professionally.

Cheese and crackers at leisure taste better than steak bolted.

Contrast is the essence of meaning.

Where there is cultural contact there will be gene flow.  It’s in the nature of young men and women.

Separation anxiety is a universal human emotion.

A toddler, given an object, will find a way to insert that object into an orifice.   

A cut needing stitches raises suspicions of a family under stress.

 People who don’t sleep well get sick.

You can’t know what you can’t know.

Stress and alcohol make things worse which makes drinking under stress a bad idea.

A thin young drunk runs faster than an aging, overweight, well equipped cop in Kevlar, but doesn’t get far because the cop can run in a straight line.

If you’ve seen more than three doctors for the same problem, the chances that I’m going to make you better tonight are not good.

No one can count anything after two drinks, especially not the number of drinks.

Every day I see patients I will see at least one thing I’ve never seen before.

Most lifelong scars are acquired under or near the influence of alcohol, before the age of 10 or between puberty and 25.

Things that seem like a good idea at the time turn out to be a really bad idea when alcohol is included.

High emotions make for high learning.

Every doctor faces information overload; prioritize or be swamped. 

The wonderful parts about day-to-day life lose their wonder when they come every day; but when we go and come back we can relish and savor the ordinary.

The line between work and friends got blurrier and blurrier as the years went on.

Economists have shown that people get happier in proportion to their money only until they’re slightly over the poverty line, then they get more unhappy with every extra dollar.  So don’t buy a lottery ticket, you might win.

More happens in a day of sitting around camp on an island than I care to write or than my audience would care to read.

All work and no play make Jack a dead boy.

Interpersonal respect, hours, money and benefits much be considered as a whole package.

If all the doctors had a sudden attack of sanity and stopped working life-shortening overtime hours, there wouldn’t be enough doctors.

Dead-end and bitterness define each other, and sap the joy from life.

You’ll enjoy the trip a lot more if you’re not in a hurry.

Forty years changes you more than it changes the road.

Chronic pain cannot be controlled in the absence of good, restorative sleep.

A year to the day, and the world didn’t end.

May 21, 2011

The moment is now and right here

It’s something precious and dear

     I journeyed because

     Of a non-compete clause

Now, to the day, it’s a year. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical while my non-compete clause expires and I dance back from the brink of burnout, I’m having adventures and working in out-of-the-way places. Right now I’m living in Amberley and working in Waikari, less than an hour from quake stricken Christchurch in New Zealand’s North Island.

Contrary to predictions, the world didn’t end today.  The earth’s destruction was supposed to start with earthquakes in New Zealand.

Christchurch suffered a large earthquake in September 2010.  The following February, a less powerful, closer temblor ripped the heart out of the city.

Geologists say that buildings near a fault line should anchor on bedrock, but Christchurch’s founders built on swampland, and the city rose on saturated soil.  If you shake dirt enough it acts less like a solid and more like a liquid, in proportion to its water content, and Cantabrians still talk about the stink of liquefaction.

Over tea at the clinic the nurses casually mention shattered heirloom china and crystal; they smile when they recount seeing cupboard doors open after the first quake and nothing broke

Yesterday two of my patients announced plans to return to Christchurch, asking for medication enough till they re-establish with a new doctor.

Nobody mentions the half-dozen GPs who died when the TV building collapsed around them; most have forgotten.

***

Three hundred and sixty-five days ago I walked out of The Clinic Formerly Known as Mine.  I worked there twenty-three years.

The decision to leave did not come lightly.  You don’t work for a couple of decades in one place without putting down roots. 

I was dancing on the edge of burnout.  I didn’t realize how close I’d come till I went back and read my posts from the spring of 2010.  But Bethany knew, and she supported me completely throughout this odyssey.

When I signed on with my old outfit my contract specified that I couldn’t work as a family practitioner within 30 miles of Sioux City’s city limits for one year.  That paragraph, enforceable when I signed it, would not hold up in twenty-first century Iowa court.

Still, I am a man of my word.  And if the desire to slow down provided my motivation for my career change, it made no sense to move straight across town and have my patients follow me.

I picked the best time in history to go walkabout.  The world has never been safer nor more prosperous; information, transportation, goods, and food have never had such quality and accessibility.

None of my original plans worked out, and I have learned that I have more fun with my second choice than my first, and to enjoy the moment that I have.

Today we walked around Amberley in perfect weather, with gloriously clear blue skies and bright sun.  Our dessert out reminded us of our wedding cake.  We have reveled in our second honeymoon.  We didn’t plan it that way.

A day at the beach, the winery, and shopping in the aftermath of disaster

May 17, 2011

Really, this day is a peach

With a winery well within reach

     In the wake of the quake

     Please make no mistake

We started off down at the beach

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and seeing patients in Waikari, in New Zealand’s South Island, an hour outside of Christchurch

Kiwis in general have a healthy, laid back approach to life.  New Zealanders value hard work and maintain a strong work ethic, but appreciate their time off.  Most New Zealand doctors don’t work five days a week.  For the majority of physicians, a full schedule means an entire day off during the week, which balances a night on call.  At the clinic where I covered in the North Island, half the docs worked part-time at three days weekly. 

I get Tuesdays off here. 

We slept in till the day lightened, breakfasted leisurely and set out for an olive grove, which we found closed, so we went to the ocean.

Amberley sits close enough to the sea to have its own beach.  The Pacific stretched unblemished out to the east.  We walked on grey sand and over accumulations of pebbles and fist-sized rocks.  We had strong winds, bright sun, and mild temperatures, with the southern hemisphere marching through autumn with five more weeks till winter.

We drove into Rangiora for lunch and grocery shopping.  A bustling suburb of Christchurch, we found well-stocked stores, smiling people, and lots of traffic.

In the afternoon we returned to Amberley and a tasting at the Mud House Winery.  Bethany sampled, I drove.

We don’t drink much, but New Zealand has world-famous wines, and we’re struggling to learn more.  Bethany tried two Pinot Gris and two Riesling vintages which left her (unsophisticated) palate underwhelmed.  I learned that the marc (the grape skins and seeds) quiets the domesticated red deer stags, making them more tractable.  We talked to our sommelier about the outstanding menu; she advised us to make a “booking” (= reservation) because, in the aftermath of the Christchurch earthquake, more people make the journey to dine on Sunday.

The aftershocks still rock the region; the public emotions remain far from recovery.

The coroner dealt heartrending news to the public yesterday, issuing eleven death certificates when no bodies could be found in the wake of the recent disaster.  After the earthquake, a man made an emergency call pleading for help.  With emergency systems overwhelmed, the operator took the names and conditions of the people he was trapped with.  Two hours later a call to the number went straight through to voice mail; text messages to the same number received no return.

Fire ripped through the area; if human remains came to light, neither DNA nor dental records could help.  Yet the coroner could piece together the movements for all eleven missing.

Yet life goes on around Christchurch, though the heart of the city collapsed in a massive earthquake on February 22.