A Doctors’ Trade Show

I went to the doctors’ trade show

And met some folks that I know

And made some new friends

Who have the means to the ends

And, all in, all, seem like a pro

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, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

After a three hour lecture in the morning, I went to the Exhibition Hall, a trade show for an audience of 4,000 doctors.

All the big drug companies have booths here, where “booth” can mean a display with 4 figure square footage, 6 figure inventory, double digit staff, high-tech lighting, and luxurious carpet.  The device manufacturers send representatives, too, along with recruiters, hospital systems, healthy and unhealthy food manufacturers, shoe makers, massagers, electronic EMR companies, publishers, lab companies, financial managers, 14 government agencies, imaging corporations, instrument manufacturers, market research concerns, office equipment vendors, practice management consultants, and almost everyone who wants to hire a Family Practitioner.

I could not find the company that made the recalcitrant EMR which led to my departure from Community Health back home, probably for the best.  That company’s exit from the field would not surprise nor disappoint me.

I visited the booth of the Urgent Care company I’ve worked at this summer, and bubbled over at how much I’ve enjoyed the experience.  They plan to open a center 4 hour’s drive from my home, and they offered me a more permanent spot.  All they want is a commitment to 10 shifts a month.

I also visited the representatives of the company that place me there.

But first I had a most productive talk with the Canadians, and I learned a good deal.  They explained some salient points about the credentialing process which the website does not make clear, especially regarding notarization of credential copies.  I established a relationship with a recruiter for a government agency, and expressed my willingness to work rural establishments.  The first step, a provisional license, will require a 3 month commitment, and, after that, I can do locum tenens work as I choose.  The country’s socialized medical system regards the doctors as independent contractors, and most work fee-for-service.  Medical malpractice exists, but a doctor has to really screw up to get hauled into court, and professional liability insurance, provided by a government agency, has remained affordable.  I walked away stunned.

Scenes from a convention

I came to get learning specific

In San Diego, out by the Pacific.

I took lots of notes

and paraphrased quotes

But the coincidences were really terrific.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska and an educational trip to the AAFP Scientific Assembly in San Diego.

I walk into the San Diego Convention Center, my third time here for the American Academy of Family Practice Annual Scientific Assembly.  It still smells like San Diego, the ocean, the palms, the sea.  I stride from one end of the Center to the other, counting the steps and making note of the time, further than my commute from my cottage to the Medical Center in Petersburg, Alaska.

I have the handouts in my backpack.  In years past the book swelled from a couple of hundred pages to two thick binders.  Now they exist on a simple thumb drive.  The same backpack carries my iPad and its associated keyboard.  Last time I came I used a smaller keyboard and my Palm to take notes.  Light and easy to carry, it could beam but not email data.

Now instead of a cell phone I have a smart phone, and I download an app that gives me the course listings with times and places and lets me enter my CME (continuing medical education) credits as they happen.  When I first came to the AAFP convention the words smart phone, Wi-Fi, download, and app did not exist; wireless meant radio, usually two-way, in stodgy British, and the word router denoted an electric wood-working tool.  If you said high-speed net service you might have been laughed at but if you used the term repeatedly you would probably get locked up.

The Exhibition Hall stretches for a cavernous quarter mile inside the Convention Center.  Big Pharma, now barred by law from giving out toys, flashlights, pens, or note pads as advertising, concentrates on pitching drugs.  My Community Health Center patients, half of whom have no resources and no money, can’t afford the new drugs.  But I stop at the Lilly booth and thank the reps for their company’s generosity; they give my facility an enormous quantity of insulin for free.

The lecture on smoking cessation strategies features lackluster content and a passionless presenter.  My attention wanders, I yawn, I try to keep myself awake doing carpal tunnel stretches.  I nod off, then I fire up my iPad and read my email.  I look around and see other attendees either with eyes closed or with their faces illuminated by their portable screens.  No one pays attention.  Five minutes from the end of class I pull out my Droid to try to enter my CME credits, and find I can’t do it without a major workaround.

Even if Big Pharma can’t give us advertising freebies, they can serve us fantastic meals and hire gifted teachers to lecture us.  While I munch an outsized turkey sandwich I marvel at the teaching effectiveness of an FP from Pennsylvania.  She speaks with dynamics and enthusiasm and imparts information I’ll retain after the drug comes off patent.  Except she never mentions a new drug or even an old drug; she talks about urine sugar reabsorbtion and diabetes.

Bethany and I sit down to lunch the next day with a young doc in the Indian Health Service; she nurses her infant while we talk.  At the end I challenge her to keep track of her hours for two weeks, use that number to figure out how much she’s getting per hour and compare that rate to locum tenens.

I run into a doc I knew in residency; I run into him six times more in the course of four days.  Then I run into a doc who now teaches in that program.  In the hotel elevator I run into two more FPs who finished the program and still work in Casper.

One evening Bethany and I dine with a doctor who still works at the Practice Formerly Known As Mine.  At the end of the meal we stroll along the marina.  We come to the Vibrant Curiosity, the world’s 60^th largest yacht.  We had seen the 5 story wonder coming up Wrangell Narrows while we were in Petersburg.  We make jokes about how the owner must be following us and the next thing you know it will come cruising up Perry Creek.

True coincidence occurs but rarely.  But I don’t know what it all means.

Bipolar, sandwiches, CME, and intellectual honesty

Genetics are mostly to blame

For bipolar chemical change

    Despite volume loss

    The amygdala’s boss

Of structures all over the brain.

To maintain licensure and certification, doctors have to complete a certain amount of Continuing Medical Education, or CME.  My state license requires 30 hours, my board certification demands 50.  Most years I stop counting at 200 hours. 

Audio Digest, a subsidiary of the California Medical Association, records CME lectures around the country and provides credentialing for the activity with a pre test and a post test; I listen to one of those lectures a week in the car.

I attended the American Academy of Family Practice Annual Scientific Assembly in Denver last week, and I finished with about 20 hours.  In other courses I’ve walked away with 54 hours in 5 days and an overloaded brain.  I decided to enjoy the lectures this year.

Arcane regulations govern what counts as CME and what doesn’t.  Yesterday, over the noon hour, I went to a lecture about neurophysiology in bipolar disease.  (We used to call bipolar disease manic-depression; people cycle from really high highs to really low lows.  Most of my best friends have been bipolar.)  No CME credits were offered.  I confess that if the lecture hadn’t come with a sandwich I probably wouldn’t have attended.  (On the other hand, CME might have been offered if there weren’t a sandwich.)

A drug company sponsored the talk and bought the food.  I expected biased information about a drug.  I depend on the data from Big Pharmaceutical being biased; certainly a company won’t tell the whole truth about their drug but the competition will fill in the gaps.  Such is the nature of capitalism.

I do not remember the name of the sponsor, and the only drug mentioned, lithium, has been off patent for decades.

The lecturer was dynamic and passionate about bipolar disease.  He does research on the problem using the functional MRI; he showed himself to be quite knowledgeable.  During the lecture, the docs kept turning to each other and saying, “I didn’t know that.”

Every attack of bipolar mania leaves structural changes in the brain; the more attacks one has, the more attacks one gets and the harder stabilization becomes.  Getting the illness to symptom control decreases structural changes but not as much as bringing the disease to remission.  The left amygdala (funny how that brain structure keeps popping up; see my post entitled “Rage, Hunger, Lust, and Sleep”) shrinks in bipolar disease, proportionate to the severity and number of attacks.  While the left amydala loses volume, the activity increases, but the right amygdala doesn’t change.  The centers which govern impulse control change in size and activity, as do a number of other structures.  Treating with lithium, still the most potent bipolar drug, reverses the volume loss changes but not completely.

I find no moral dilemma in accepting food from a pharmaceutical company, as long as I maintain a similar relationship with their competition.  The current ban on small gifts to doctors such as pens and notepads insults the intelligence and integrity of the medical community but it cuts down on the clutter and junk in my office.