Posts Tagged ‘Barrow’

What does “call” mean? Don’t look in the dictionary

March 26, 2017

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

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.

People can use the same word to mean different things, and the same person can use a word at different times to mean different things.

For example, when I worked in the Indian Health Service, “call” started at 4:30PM and lasted until 8:00AM. Weekend call started on Friday afternoon and lasted till Monday morning.

In my years of private practice, it started at 5:00PM and went till 7:00AM. The doc who took Friday evening call worked the clinic on Saturday from 9:00AM till 2:00PM.  The physician with weekend call started Saturday as early as he or she wanted, rounded on the patients in the hospital, and took care of admissions till 7:00 Monday morning.  For a long time we saw the patients who came to the ER, but that faded over the years.  The on call doctor did the obstetrics over the weekend.

Call in Barrow (now called Utqiavik) never meant anything other than 12 hours, weekend, weekday, or holiday.

In Petersburg, the physician on call also covered the emergency room.

In western Nebraska, being on weekend call meant doing a Saturday clinic till noon, rounding on patients Saturday and Sunday, and admitting patients from the ER.

In Metlakatla, where we had no hospital beds, the two main ER nurses had excellent clinical skills. I could rely on them to know when I needed to come in and when I could safely wait to see the patient in the morning.

I have call this weekend, starting at 8:00AM on Thursday and going to 8:00AM on Monday. During that time, I’ll round on the hospitalized patients.  But someone else will work the Emergency Room.  If a patient needs admission, the Emergency doc does an admit note and writes admitting orders.  If a patient needs me to come in and see them before morning, they generally need to be at a larger facility.

I have had two nights of call so far. The first one passed without my phone going off, not even once.  The second time I worked steadily till 9:00PM stabilizing a very ill patient for transport.

But what does call really mean, here, this weekend?

I can tell you on Monday.

And I can guarantee it won’t mean the same thing a month from now.

Finishing early=playing hookey

March 22, 2017

The morning went just a bit slow

And I left with an hour to go                                              

But with the time I had freed

I got in some read

And enlarged the stuff that I know

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.

Last night Bethany and I had the chance to tell my story to a housemate. Coming up to my 60th birthday I knew if I didn’t slow down I’d burn out.  But I had a one-year, 30 mile non-compete clause.  That’s when I went to Barrow, Alaska, the northernmost place in the US.

Bethany recounted the time I called her to say that I had put in 63 hours that week, but I had time for the gym, playing my sax, participating in a jazz group, recreational reading and writing, socializing and watching TV. I initially attributed the extra time to commute reduction and other factors inherent in living in a small community, but then I applied the same criteria to what I’d been doing in private practice and came up with a conservative estimate of 84 hours a week, not counting obstetrics work.

Nowadays, any work week shorter than 60 hours feels like vacation. And when I walk into the clinic on Mondays, my steps bounce and I grin because I love the work.

I love it passionately up to about 50 hours, and after that my enjoyment starts to decay.

And I think my patients can tell when I get excited about a diagnosis. And when the patient makes my day, I tell them so.

Since I got here I’ve been able to radically help about a dozen patients with either Parkinson’s (involving tremor and stiffness) or PMR, polymyalgia rheumatic (an inflammation of the arteries).

But as influenza season wanes, so does the patient flow. This morning I had no inpatients at all.  Of my two scheduled morning patients, the first one showed on time at 9:00 and the second at 9:30.

I used the hours to read up on PMR . It overlaps with giant cell arteritis (GCA) and temporal arteritis (TA).  Because it comes in clusters, some authorities think it might be viral, and, indeed, if a biopsy of the temporal artery (which runs from right in front of the ear up into the scalp on the side of the head) shows TA, 3 times out of 4 it has the chickenpox virus in it.

Bethany met me for lunch.

In the afternoon I did some more work on my Canada license. I read up on Parkinson’s disease.  I saw 4 patients and finished their documentations.  Throughout the clinic, calm and low patient flow prevailed.  I got permission to leave at 430PM.  Bethany picked me up outside the front entrance, with a stiff March breeze blowing.  She took one look at me.  “Feel like you’re playing hookey?”  she asked.

I nodded. I had only worked 9 hours.

Christmas? Easy. The day after? Difficult transport

December 27, 2015

For ambulances, we have only two.

The blizzard came out of the blue

It stormed and it snowed

All the way down the road

That’s the reason that nobody flew.

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. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Christmas went quietly, and I only write that after the fact because I don’t want to jinx myself by saying good or bad when people ask me how the call is going. I always say, ask me when it’s over.

I used to work at a place which regarded the holiday as lasting 5 days, with me on the hook for 120 continuous hours. The second year I started with a census of 38 hospital patients  At the end, with a grand today of 20 hours of sleep, my work quality had degraded significantly in that I had quit caring.  The following year I absolutely refused to carry the beeper for more than 72 hours.  Management voiced their objections, which I noted, and used the phrase “patient safety” in my reply.

I don’t work there now.

So far here in Nebraska I haven’t worked more than 50 hours a week. When I go home, I go home.  The term “call” carries no meaning; I have no beeper and they expect me to turn my phone off at night.

I finished my Christmas work before noon, went to the gym, and got back home in time for lunch.

This morning, the day after Christmas, I went in to make hospital rounds and staff the Saturday clinic. I crept down icy asphalt, a strong north wind threatened to blow me off the road.  Just as I pulled into the parking lot snow started in earnest.

I can’t talk about individual patients but I can speak to the aggregate: all could remember the start of World War II, and all could remember the Armistice Day Blizzard of 1940.

One patient had improved enough for discharge.

The medical end of the discharge process came easier than the EMR. I ran into a 16 item set of blocks requiring responses.  I clicked in a couple of places, got no response, muttered in Navajo (the only per se taboo words have to do with the government), clicked again and nothing happened.  Eventually I asked for a consult from the ER doc.  By the time help arrived I figured out that my computer had locked up and needed restarting.

One patient, having failed to respond, required transport to Omaha, but the weather had worsened to blizzard conditions and no one would fly. The town has two ambulances, one had yet to return from a transport in the wee hours.  So my patient’s transfer would have to wait for a loaner from another community or the return of our other ambulance.

I looked outside at the whiteout, and I thought of Barrow, where weather prevented flying an average of 1 day out of 3, and the flight would last a minimum of 5 hours. The ground transport to Omaha would last a fraction of that, with several other hospitals along the way if the conditions worsened.

Saturday clinic welcomes walk-ins but has no appointments. I saw my first patient at 10:15AM.  I have gotten enough fluency with NextGen that the documentation flowed.  I took care of 5 out patients.  One had an alarming physical finding I’d never seen before.

At the end of clinic I bought delivery pizza for the skeleton crew. We usurped the conference room and chatted.  When I walked out, the snow had stopped but the wind, if anything, had freshened.

I didn’t have to scrape the windows.

 

A breakfast meeting with a new colleague

December 13, 2014

A respite that’s every so fleeting

From the diseases we find ourselves treating

I sat down to talk

With a colleague, a doc

An informal at-breakfast meeting

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 for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years.  I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system.  Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.

During my time in Barrow, Alaska, the doctors met every morning from 8:00AM to 9:00AM.  We reviewed admissions, evacuations, problem patients, and interesting cases.  The agenda rotated around the table, everyone had a chance to talk and everyone had something to say.  Each time I left the table a better doctor than when I sat down.

When I returned home after my walkabout year, I fell in with a couple of colleagues who had also worked in Barrow.  We breakfasted together once or twice a month, and the informal meeting always made us better doctors.  Neither of those docs works in town now.

I breakfasted with a new colleague, Board certified in both Psychiatry and Family Practice.  I got to tell her about the Old Days, when med schools actively excluded women, doctors could hit patients but only when they deserved it, laparoscopic surgery existed exclusively as an idea in my head, and the diagnosing primary care doctor earned a lot of money as the surgical assistant.

I told her about the funeral I’d been to earlier in the week (see the previous post), and the amazing surgeon I’d had the privilege to know and work with.

Over semi-scrambled eggs with mushrooms, onions, and smoked turkey, I laughed with her at her vivid description of her embattled clinical situation.  As with most who work in community health and/or with the mentally ill, she faces an impossible situation of inadequate resources and challenging patients.  She compared it to a battlefield front-line aid station equipped only with eye-patches.

We discussed obstetrics, how much we both enjoyed it and how much I enjoyed stopping.  We agreed that the feeling in the room immediately after a birth carries an evanescent sense of perfection not found elsewhere in this life.

I got to talk about how I learned how not to interrupt the flow of feminine energy in the process of a delivery.  I have found this concept nebulous and difficult to teach and embarrassing to talk about in the company of the coldly analytic.  Nonetheless when I figured it out the deliveries went better.

But I didn’t sugarcoat the problems that I had at my last delivery (see the post from April 2010, https://walkaboutdoc.wordpress.com/2010/02/24/my-cancer-removed-reflections-on-being-a-male-in-ob-a-frightening-delivery/.

We discussed beepers and the psychiatric community and why the dynamics roll the way they do.  And we talked about writing.

She might start blogging.

Whales, eagles, and salmon

August 18, 2013

The fish will never ask why

Their biology demands that they try

The end couldn’t be sadder

For at the end of the ladder

The salmon spawn and inevitably die

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 taking a working vacation now in Petersburg, Alaska.

Life in Barrow, Alaska finds the rhythm of its heartbeat with the whale, Keosauqua with the deer.  Our home town of Sioux City, Iowa breathes with the corn cycle.  Petersburg, Alaska has its pulse with the fish, in particular, the salmon.

A Norwegian fisherman opened a cannery and founded the town about a century ago, and Petersburg has depended on salmon since.  They also catch cod, crab, shrimp, and halibut, but without salmon, the town wouldn’t exist.

Nine hundred seasonal workers came this summer to work 16 hour days in the canneries, and you can find no more than two degrees of separation between anyone in town and the fishing industry.  By the time someone finishes high school here, they have worked in that industry at some level, whether on a fishing boat or in the cannery.

Today we drove out to Hungry Point and watched the same humpback whales we’d seen in Maui.  We had brilliant conversation with two tourists from Australia.  We went a bit further down the coast to Sandy Beach and watched pink salmon desperately trying to swim upstream to spawn and eagles leisurely waiting to feed on them.

We enjoyed the spectacle, and talked to some people from Petersburg.  The rainfall ran short this summer, and the beautiful clear days have come at a price; one can’t have a rain forest without rain.  Streams have to have adequate flow for the salmon to swim.

People who live here will readily say that king, or Chinook salmon taste best, followed by red (sockeye) or silver (coho).  They speak with disdain of the pink (humpies), saying they’re good for cat food.  And no one even mentions the chum or dog salmon in terms of human food.  Yet the canneries this year will mostly process the pink salmon.

We drove out south on Mitkof Highway along the Wrangell Narrows.  We found the fish hatchery closed, and by then the good hard rain made viewing salmon swimming impossible.  On the way back to town we stopped at the Falls Creek fish ladder, which we found despite the abysmal signage.  While the rain came harder and harder we stood and looked over the concrete, manmade steps that parallel the roaring rapids.

It took a while till we knew what to look for, then the drama of the eternal struggle of life’s longing for itself played out in front of us, salmon desperately swimming against an overwhelming current to find a place to lay and fertilize eggs before they die.

No Pacific salmon survives the reproductive process.

A great day in the face of adversity

June 26, 2013

The computers slowed down to a crawl.

A hammer would have started a brawl.

But you can give us an A

We had the best day

In all the clinical hall.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

Usually, Monday morning opens with hospital rounds.  Today I started early and finished early.  I had time to get to the VA to have my TB skin test placed and have FedEx send off a packet of materials in preparation for a 2 week job in southeast Alaska in August.  When I arrived at the clinic at noon I found the atmosphere tense.

Our Electronic Medical Record (EMR )system has problems, and every few weeks brings us another crisis.  Frustration builds as the system slows down.  By 1:00PM it made a glacier look positively zippy.  Then it started to sputter, shutting down completely from time to time.

The mood of the clinical corridor darkened as the work flow slowed.  I went downstairs and stuck my head in the Information Services room.  “Are things going to run this slow for the rest of the day?” I asked.

“I’m afraid so,” came the answer.

A lightning strike in a distant city had melted links in out communication chain.

I walked down the hall and asked an administrator to come up to experience the problem.  When we got to my computer, I demonstrated the 6 minute sign on.  The PA at the next workstation volunteered that she’d been working on the same patient for the last 45 minutes.  I showed the administrator how it took 5 minutes to change patients, but the process shut down completely.  I watched facial expressions mirroring my own.  I answered a few reasonable questions, and watched the administrator stalk out.

I turned to my two nurses.  “We’re going to have a great day,” I said.

Then I thought for a minute.  “We’ll use paper.  Call everyone on the schedule who isn’t here yet and have them cancel their appointment.”

I talked to a couple of patients by phone, emphasized that we couldn’t do anything, and acceded to a request for a mood stabilizer, to be followed by a more thorough visit later.

I looked down the hallway at all the people ready to do physical violence to their computers; the frustration and the tension became palpable entities.  If hands could have found hammers easily, terrible cybercarnage would have followed.

I thought about bicycling into a tropical storm in 1972 and singing Bob Dylan songs in the rain.  I remembered playing my saxophone in the Fourth of July parade in Barrow, Alaska in 2010 under leaden skies with mixed rain and snow and numb fingers.  I turned to my team.

“Anybody can have a good time when conditions are perfect,” I said, “But things are not perfect and we’re still gonna have a good time.  Because we’ve practiced and we’re good at it.”

And we had a great afternoon and evening.

EPIC: learning another EMR system

January 31, 2013


Don’t keep this close to your vest,

It’s not something I’d utter in gest

I’ll reassure you

MedTech32

Certainly ranks as the best.

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 54 hours a week.

One of our city’s two hospitals will soon adopt EPIC, a new electronic medical record (EMR) system.  In order to have privileges, all doctors must pass competency in its use by March 1.  The hospital pays for the training.  I spent 8 hours on Tuesday at the lectures, more training will follow.

I have trained into Allscripts, MedTech32, Centricity, and Cerner PowerChart.  MedTech32, the New Zealand national EMR, comes out the winner with no close second; easy to learn, easy to use, generating useful documents, and giving quick access to data.  All the others have steep learning curves, they all produce documents swollen to uselessness.  Allscripts brought slight workflow improvement after six months of getting used to the system.  Accessing data in Cerner and Centricity takes much longer than a paper chart.

The hospital in Barrow, Alaska gave me the option of learning a new EMR but I found using paper and pencil easier.  Given my short time there, I saw no advantage to spending 20 hours acquiring a skill set I would only use for 14 weeks.

At first impression, EPIC has attractive features.  With a consistent theme and layout, not exactly intuitive, but at least learning one section carries over to another section. 

I will reserve judgment till I’ve worked with it for six months. 

The class took place in a windowless basement room I had never visited despite working in that hospital for a quarter of a century.  I knew all 5 docs in the morning session and all 8 in the afternoon.

The lecturer and the book did a good job.  From time to time things the system did not respond as advertised.  I expressed dismay, the teacher reassured me that the learning environment has problems that the “real thing” doesn’t.

I voiced my skepticism.

Still, the EMR will not go away.  That the end-user doesn’t pay for the product constitutes the main problem; not nearly enough purchasing committees learned the moral of the story of The Emperor’s New Clothes.

 The daunting task of embracing new technology puts off many docs, especially ones that didn’t grow up with computers, and the record-keeping paradigm shift becomes the tipping point for a lot of physicians to leave medicine. 

The oft-cited complaint, “I went to med school to take care of patients, not to enter data,” carries a ring of truth.  I know I’d rather take care of patients, even smelly ones, than play with computers in a dark room for a couple of days.

At least one doctor announced he’ll retire the day before the system installs.

Medical Advice at Parties.

July 8, 2012

At parties I’m asked for advice

It’s happened way more than twice

Wouldn’t you know

Sometimes I say ‘no’

But I usually try to be nice.

 

Bethany and I received a surprising number of last-minute invitations to parties today. 

People ask me for medical advice in social situations.  On one occasion, shortly after my mother’s death, I snapped and yielded to the urge to sarcasm and immediately regretted it.  Yes, the request arrived at an inappropriate time and place; no, the patient had never seen me on a formal professional basis; yes, I had every right to turn the request down.  But I did so with finesse and eloquence, a misapplication of good verbal skills.

Today I recommended the book, Love, Medicine, and Miracles in the buffet line, and a trial of over-the-counter meclizine while eating spanokopita.  I listened intently to an alcoholic’s relative, and agreed counseling would be a good idea.  I nodded while a person detailed a coworker’s headaches.

In med school and residency and even later, the docs who mentored me would say, “It comes with the territory.”  I suspect the phrase comes from traveling salesmen who would use it to describe the positive and negative things about working in a particular area.  The advantages of working in Montana differ from those of New York.

I would worry more about seeing a patient as a collection of diseases rather than as a whole human being if I didn’t talk about so many other things with the same set of people.  Today I had discussions about archery, firearms, ballistics, gardening, stone fruit, bicycles, New Zealand, and Alaska.

Yesterday I had a good talk with a friend, just back from 8 weeks of locum tenens (substitute doctoring) in Barrow.  The Inuit filled their quota of 21 bowhead whales; on one day they brought in three.   Weather socked the place in more than once, preventing critically ill patients from reaching services on a timely basis.  We agreed that Barrow ranks as a place on the fringe of the 21st century, that theft was nonexistent, and that the North Slope people smile more than any population we’ve seen.

Bethany and I spent two weeks in June in southern Alaska.  Four days of fishing, four days with friends, and four days of Continuing Medical Education with the Alaska Academy of Family Practice’s 27th Annual Scientific Conference in Kenai.  The sun set about 11:30 and rose a couple of hours later.  Which gave us a lot of time to fish but played havoc with our sleep.  Not nearly as bad as the 8 weeks of unremitting day without a single sunset the first time I went to Barrow. 

I might go back to work in Alaska, eventually, but Barrow remains outside my zone of comfort, like working in Sioux City and having the nearest referral hospital in Dallas.

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.

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.