Archive for the ‘Uncategorized’ Category

The thrills of cerumen and B12 deficiency

April 23, 2017

Real flu has cough, fever, and ache

And I know just the pill you can take

And then there’s the test,

It’s good but not best

But a decision it sure helps me make.

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I had a good week in Clarinda.

Orientation on the new job went well; I found it well-organized and well-planned.

The facility not only assigned me a scribe but also a cracker-jack Electronic Medical Record superuser to train me on the 14th new EMR I’ve learned in the last 28 months.

Recognizing the problems of learning a new system, my patients have come no more often than every ½ hour.

Thursday morning went well; I had the immediate gratification of curing the first patient by removing ear wax and the second with osteopathic manipulation.   Close to noon I received lab results on tests ordered earlier in the week, including three vitamin B12 levels.  Two borderline numbers (between 211 and 400) require further testing, and one came in frankly low, less than half the lower limit of normal.  That bit of information made my day; I can save the patient’s life with a simple injection once a week for 12 weeks, then once a month.

Bethany met me for lunch in the hospital cafeteria: well-prepared, healthy food at insanely low prices. I told about how I found my morning not only gratifying but satisfying.

Influenza dominated the afternoon. We have the clinical experience to predict that the annual flu epidemic starts in the north and works its way south, with 90% of the cases in any one location occurring in the course of 3 weeks.  I enjoy taking care of influenza; we have a clear-cut, good but not perfect, lab test and two effective drugs.  The older the patient, the more likely my prescription will prevent death.  Most of my patients here are over the age of 70 with several in their 90s.

The problem with taking care of old people is that I don’t get enough time to talk to them. I could easily spend a morning or afternoon just listening to one patient.  A person can’t get to advanced age without acquiring a large stock of really great stories.

Thanks to a light patient load and a scribe, I finished at 6:00PM. I walked out of the hospital at sunset, ten minutes across dry winter grass and quiet back streets.  We decided to drive back to Sioux City and our own wonderful bed.  We packed the car in less than 20 minutes.  The sky darkened as we traversed two-lane county roads through the rolling hills and farm country. We detoured to Trader Joe’s in Omaha, but missed a turnoff, adding an hour to the trip.

 

 

 

I take call and end up a patient.

April 23, 2017

At the end, it wasn’t a stroke

It was gone when I awoke

The symptoms were brief

Avoiding much grief

And I got to tell a crude joke.

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

Tuesday evening while on call, I got up to play Scrabble and I couldn’t make my right leg work. It didn’t feel heavy, numb or weak; it felt too light so that any effort to move it got exaggerated.   I sat down to do a neurologic exam on myself.  I found nothing other than my right leg ataxia.  I called Bethany from the next room, and told her the situation.  She helped me dress, and drove me to the ER.

The ARNP covering the ER did the same neuro exam I did, which wasn’t impressive until I demonstrated my gait.

She did all the right tests. The first EKG showed an old heart attack, which disappeared with proper lead placement.

She also found a heart murmur.  It hadn’t been present 5 years ago, but the PA at the VA found it a couple of months ago, and I called her attention to it.

My blood work had no surprises. She offered me the choice of staying in Clarinda or going into Council Bluffs, and I chose to go.  In terms of game theory, if something happened in the middle of the night, I wanted to be close enough for timely intervention.

In the process I had to make arrangements for someone else to take call.

I napped off and on for the ambulance ride, which almost got derailed twice by herds of deer. I bypassed the ER at Jennie Edmundson Hospital.  At 2:00 AM I had gotten settled, my IV had given me a couple of quarts, the second set of labs had come back and I’d had a good visit with the hospitalist ARNP.  Just before being tucked in, I offered the nurses a choice between a clean joke, a clean joke with a bad word, or a dirty joke.  They chose the last option, and I gave them the funniest crude joke in my large arsenal.

I don’t get to tell that joke as a physician, no matter how funny it is. But, as a patient, I can get away with it.  The punch line drew gales of laughter.

By then, motor control of my right leg was functioning at about 90%.

I slept for a couple of hours and had breakfast.

The neurologist arrived, and with economy of motion, did a thorough exam. He advised an aspirin a day and starting a low dose migraine medication.

The morning parade of tests started. By the time Bethany arrived I had done the basic neurologic exam six times and the symptoms had resolved except for the funny feeling inside my head.

I had an ultrasound of my neck, a consultation with the dietician (whom I amazed with my six pieces of fruit a day and my two ounces of salmon at breakfast), a consultation with the Occupational Therapist, and then the Piece de Resistance, the MRI. In between, I napped because I’d slept so lousy.

The hospital feeds its patients on the room service system; I ordered a lunch of soup, sandwich, and fruit, and within a half hour a young Guatemalan arrived with the food. We had a brief conversation in Spanish, I introduced my wife.

And we waited. The hospitalist came back, and went over the results.  Ultrasound demonstrated clean carotids (neck arteries).   The MRI didn’t show anything conclusive.  He also recommended an aspirin a day.

We waited for echocardiogram results. The hospital public address system announced a severe thunderstorm warning, and then a tornado watch in effect till 10PM.  The internet and the TV weather agreed that severe weather approached from the west.  At 4:45PM we decided to leave before the storm arrived, without the echocardiogram results.  We didn’t want to spend the night in the hospital, nor did we want to risk hitting deer on the way back to Clarinda.

Bethany drove. We enjoyed dramatic skies and listened to a Continuing Medical Education CD.  We ate at Clarinda’s premiere restaurant, J Bruner’s, ordering off the appetizer menu.

I returned to work the next day, the episode completely resolved, making it a transient ischemic attack (TIA), also call a reversible ischemic neurologic event (RIND).  Except I noticed my handwriting was much clearer.

I don’t think anyone else noticed.

Have imagination, will catastrophize. Professionally.

April 16, 2017

Here’s a subject in which I’m well-versed,

And for 40 years I’ve been immersed

When it comes to the best

I’ll just keep it in jest.

I’m paid to think of the worst.

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Some people have a thought process that involves using their imagination to the worst possible effect. They think of all the things that can go wrong, and, sooner or later, they run into health consequences from dwelling on negative things that haven’t happened.  The medical profession has a term for this phenomenon; we call it catastrophizing.   As time goes on, the catastrophizer dreams up more horrible scenarios; they come to my attention when they develop insomnia, depression, and other problems.

I try to point out to the person in question that they couldn’t have anticipated the 10 worst moments of their lives, and that none of last 10,000 terrible “what ifs” they imagined came to pass. Therefore, it follows, that just by dreaming up negative scenarios, they prevented them.  Mostly, they don’t listen.

In the daily course of my work I think about the worst things I can imagine. I’m good at it, I’m a pro.  I have talent, training, and experience.  I can think of really terrible things.

Of course, like the experience of any catastrophizer, most of the really bad things I think of never come to pass. The thought doesn’t quite cancel out the possibility; I run the diagnostic tests.  At the end of the visit I frequently say, “You want me to be wrong.  You want to walk away from the tests shaking your head and complaining about what an alarmist your doctor is.”

A patient (who gave me permission to write this) came in with terrible pain in her hands. I thought of Lyme disease and rheumatoid arthritis, and ordered appropriate tests, but I also examined her med list and decided to at least temporarily remove the most likely candidate, her statin.  A week later, the pain is gone, and she feels better.

I also did not diagnose cancer, Lyme disease, syphilis, B12 deficiency, lead poisoning, measles, sepsis, and meningitis. Despite of string of previous successes, I also failed to find folic acid deficiency and polymyalgia rheumatic.

But I went looking for them. In my case, imagining the scenario doesn’t prevent it.  But, then again, I’m a pro.

 

 

Measles, a word the 7-year-olds haven’t heard

April 9, 2017

Here’s a contagious word to the wise

If there’s rash and runny eyes

With a cough, I suppose

Look! How runny the nose!

And it’s MEASLES! The CDC cries!

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

About 3 weeks ago I received an email from the Iowa Department of Public Health about a case of measles. The person (age and gender not given) had been in the Omaha airport on March 12.  Diagnosis of measles had come on March 15, after visiting 3 different healthcare facilities.

So I was on the lookout for a disease I hadn’t seen for 30 years.

Finishing my Indian Health Service contract in 1987 at the Tuba City, Arizona Indian Health Service Hospital, I saw hundreds of cases, and I had to learn about the disease. Measles discussions center on the 3 c’s: cough, conjunctivitis (runny eyes), and coryza (runny nose); the patient looks sick, and has a fever.  The rash starts on the face, and in the next three days works down the body, concentrating in the midline, armpits, and groin.  The 3-day or German measles has a similar looking rash that also starts on the face and spreads down, but people don’t get nearly as sick.

At the time, that reservation had an immunization rate close to 100%, but when the dust settled, the case count came very close to a 5% vaccine failure rate. Since then, the MMR has gone to a two-dose immunization schedule.

With the alert fresh in my mind, I had reason to think of the things I learned and saw so many decades ago. Working a game of incomplete and imperfect information, I called the state Department of Health.  Connecting eventually with an expert who had never seen the disease, but knew what to order, I heard for the first time of a viral transport medium called M4.  And I learned to use a culturette or a Dacron swan, not cotton and certainly not wood.

We still have no treatment for the disease. And with the illness almost extinct, we probably won’t invent one.  Yet measles still runs into complications in almost 10% of those who have it.

Exposure confers lifelong immunity, and only humans can get measles. Thus as an undergrad in anthropology, in one class we did calculations based on 2 week contagion, 3 week incubation, and generation length of 20 years to figure out how what size population can support the disease.  We decided, eventually, that measles couldn’t be more than 50,000 years old.

Measles remains contagious in the air for 2 hours after a person with an active infection leaves a closed room. Thus the case that triggered the alert, arriving on an airplane, exposed a lot of people.

I want to know about that case. What irony or drama surrounds the circumstances of inadequate vaccination?  Who did the exposing, and how sick did that patient get?  Where was the exposure, and was it linked to the Disneyland outbreak?

I never had measles as a child. The son of a physician, I served as a test patient when I was 14 for the first measles vaccine that only served to deplete what my meager natural immunity.  I had to wait till middle age to get an effective vaccine.

Later that day I asked a 7 year old if he’d ever heard the word, measles. “No,” he said, “What are they?”

The antivax movement makes no sense. Mercury has been removed from the vaccine, and all the evidence linking MMR to autism was fabricated by one researcher who has since owned up to his deception, yet that myth persists.

I fear that the antivaxxers may get enough traction to let the genie back out of the bottle, and that the word, measles, may once again become part of the language.

The blizzard to home

March 1, 2017

There’s the net, and we know what we know,

But if something’s uncertain, it’s snow

Is it foolish or bold,                                       

To make a trip in such cold?

Or just plan on making it 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, 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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I kept an eye on the internet weather predictions on Thursday preparatory to the drive back to Sioux City, and I could see snow predicted for the evening, but the really hard snow wouldn’t start till after midnight. Bethany and I talked about the trip over lunch.  We decided to try to get as far as we could, and, if necessary, stay the night in a motel in Onawa, about 50 miles from home.  We left in light rain mixed with sleet.  Our neighbors called before we reached Omaha.  The blizzard had engulfed our destination.

We talked it over some more. We decided that even if we could get to Onawa, a closed Interstate at that point would mean full motels.

If we’re going to get stuck, we said, we’d rather get stuck in a town with a variety of good restaurants and an overabundance of rooms.

We dined at the Jaipur, and while we tried a couple of dishes we’d never had before, the snow-covered the car to a depth of 3 inches.

We crept down icy streets to a nearby motel.

We hadn’t even brought a change of clothes, but the front desk had toothbrushes with tiny tubes of toothpaste.

We slept hard and deep and awakened rested to find, after breakfast, the car encrusted with ice and coated with heavy, wet snow. The trunk, frozen shut, required a good deal of coaxing to open.

As I pulled onto the Interstate in Omaha, a car intending to take the same ramp from the other direction spun out while I watched.

Between the two of us, my driving talent lies with traffic, and Bethany’s with snow and mountains. I got us out of Omaha and headed north on I-29.  At the first rest area we changed drivers.

On the way to Sioux City we saw two more spin outs and a half-dozen cars off the road, one on its roof.

The drive took twice as long as usual. But we arrived, safe and grateful.

It snowed and it blew but the cold didn’t approach the negative double digits we’d planned on in Fairbanks. Still it’s all part of the adventure.

 

 

Great hospital food and a chili cook off

February 25, 2017

In some places, the chili has meat

In others watch out for the heat!

I might cause a scene

But I won’t use a bean

And the cocoa I might have to delete

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I find money. Mostly I find small change, a nickel here and a dime there, on a handful of occasions I’ve found enough to actually buy something with.  Finding a dime when McDonald’s had 15 cent hamburgers meant a lot more than finding a quarter now.  For the most part I use credit cards for business transactions, reserving cash for small vendors, and before Clarinda I had gone out of my way to avoid carrying coins.

But the cafeteria here serves very good food. I carry change now because I can buy a great lunch with it.

Working locum tenens has given me an appreciation for the wide variety of hospital food. In Barrow they cooked with love and imagination, and if I had had a party I would have tried to get them to cater.  I ate for free there, but Bethany paid $10 per meal, reasonable for a place where airplanes bring groceries.

At another place in coastal Alaska they either overcooked or undercooked everything but the soup, and charged way too much. In a couple of places I didn’t get an employee discount.

And in one hospital the cafeteria consisted of nothing but a bank of noisy vending machines. Bethany packed my lunches during that assignment.

Last Thursday Human Resources sponsored a chili cook-off.

Chili in Texas means tomatoes, beans, and burger; chili in New Mexico always has chiles, sometimes has meat, occasionally has tomatoes, and never has beans. Like a number of other things in human experience, different people can use the same word and mean different things.

Employees paid nothing for the chili that the contestants brought in, but the dietitians made cinnamon rolls available for $1. The cafeteria even made a very decent house chili, and served it for free.

Of course I entered my mole (pronounced moe-lay; it relies on a balance between chocolate and tomato). Too spicy for the mild category and too mild for the spicy category, it didn’t win any prizes.  Or maybe because I used chunked turkey instead of beef, and didn’t put any beans in it at all, thus it probably didn’t look like chili as people in Iowa understand the word.  I may have to change my recipe.

 

Flu and less than fluent Mandarin

February 24, 2017

There was an old lady who contracted the flu

She went to the doctor who knew what to do.

He said, “What is best,

Are fluids and rest

And perhaps a drug that is new.”

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

The havoc that influenza wreaks each year impacts the entire medical system. Predictably, the epidemic starts in the north and works its way south, spending about 3 weeks in a population center.  If multiple strains circulate, each one follows the pattern.

The CDC follows the annual flu disease activity by watching the death rate; when it spikes to 150% of yearly average, we know that the influenza has arrived. It represents the peak demand on the medical infrastructure.

Some of those excess deaths come directly from the flu, but we also see spikes in the rate of mortality from heart attacks, strokes, and just about everything else. If a person has been clinging to life, hanging on by a thread, the influenza is the knife in the hand of the Grim Reaper that cuts that thread.

At 745 on Tuesday, I discovered I had 6 inpatients including three new ones who would need a complete history and physical. Still pretty green with the hospital computer system at that point, I wandered electronically till I popped up a patient list of 10 names.

The worst flu I ever saw came in 1993. I had responsibility for 45 nursing home patients in 3 different institutions at that time.  One morning I received a call at 930 saying that a patient of mine had, that morning, developed a dry cough, fever, and muscle aches.   I ordered a flu test and amantadine (a good flu drug for more than 30 years, but it had a lot of side effects and about 8 years ago it completely lost its effectiveness).  At 1000 the nurse called back to tell me the patient was dead.

I visited that nursing home for regular rounds a week after that. I could read the shock and loss on the faces of the staffers, the grave stones in their eyes.  The had lost, on average, a patient a day for the last week and a half.

Twenty-four years later I faced a hospital census in the middle of flu season.  I don’t wager, but if I did, I would have bet that most of those who had sickened to the point of needing hospitalization did so directly or indirectly from the influenza.

But I still had a clinic schedule. I got a lot of exercise between my clinic office and the inpatient nurses’ station. At the end of the day I left the hospital with sore ankles and a backlog of documentation.

Bethany and I and a med student (who has been staying in the hospital guest house) walked a mile and a quarter (2 km) to a Chinese buffet. But I strolled for the sake of conversation instead of racewalking. We had some really excellent food, and I got the chance to show how badly I speak Mandarin.

 

 

Tagalog, flu, and a staff meeting

February 14, 2017

The patients still suffer the flu,

And I know just what I can do

Though to prevent what they’ve got

We’ve a pretty good shot

But I’m hoping for some drugs that are new.

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, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Most sick people want to get well, and even more don’t want to be around strangers. I’m filling in for a doc whose patients love her.   They won’t come in until they feel sick or worried enough, and I haven’t had time to build a reputation in the community.

I attended one patient every half-hour from 9:00 till 11:00. I ran 5 lab tests, and ordered one x-ray.  Half the patients got prescriptions, half of them got advice because pharmacologic management would have been a good deal more dangerous than helpful.  With the unseasonably warm weather, I advised two to get over the counter Flonase for allergies. Another patient got a simple 5-day prescription that may very well save a life.  One patient has me puzzled and awaiting labs.

I exhausted my very meager Tagalog vocabulary on one person (who gave me permission to write this), prompting my patient to ask me if I’d lived in the Philippines. I explained that the most educated immigrant minority in this country are the Philippino, with a disproportionate number of doctors, nurses, and pharmacists.  Of course I’ve had colleagues from that country.  And, inexplicably, on the North Slope of Alaska, the Tagalog speakers dominate the taxicab business..

Three patients smoked; for each one I held my forefingers 18 inches apart and said, “On a scale of 1 to 10, how ready are you to quit smoking?” No matter what number they came up with, I asked, “Why not 2?” but had to explain that the doctors had already told them the bad things about tobacco, and I wanted the patient to tell the doctor something good about it.  One patient shook her head and said, “You’re good.”  I had to admit that I’d gotten the technique from an educational CD.

We had our monthly med staff meeting from 12:30 to 2:00. They announced my successful vetting (in the trade, we call it credentialing).   We went over changes in the Emergency Medical System (EMS), and talked about criteria for blood transfusions.

The flu came up briefly; the annual epidemic started about 3 weeks ago. It’s weakening but it’s still going.

I had no patients on the schedule after 2:00, and I started reading the handbook that HR gave me. I had two patients after 430, finishing at 6:00 sharp.  I walked out with all my work done.

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.