Posts Tagged ‘Canada’

Talking Canadian Licensure With a Canadian

August 31, 2018

To her home the doc wants to go back

It took time, but she’s facing the fact

She has nought left to prove

So she decided to move

I told her she just needs to pack

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I had a good long phone conversation with a Canadian national, a physician working in the States considering going back home, for a lot of reasons.

Right now she attends patients in a high-crime area with brutal heat and humidity, in the sunniest part of the sun belt. She loves teaching, and she loves medicine.

She talked about her aging parents in Ontario. She asked me about scope of practice and professional climate for docs seeking licensure in Canada.  And how to go about the process.

Honesty seized me. I couldn’t talk about her specialty or academic medicine at all. I could barely talk about big city medicine.  I told her how much I loved my spot in northern British Columbia and what huge hassles I’ve been through to work in Canada.

I couldn’t tell her what difficulties she’ll find getting licensure in Ontario, because Ontario is not British Columbia. After all, my Alaska license came easily, my Pennsylvania license did not.   She will not face the 5 months of ricocheting emails caused by hard-to-read signatures on 35-old-residency certificates, nor another 5 months of frustration caused by accidents of history in the development of Family Practice training.

She probably won’t face a 7-month dead-end with a private recruiter.

She won’t need a work permit because she’s Canadian, and she probably won’t need a physical.

We swapped bits of our backstories. I talked about how my curiosity got me north of the border to start with, but how the practice climate keeps me coming back.

We talked about how the insurance industry and government (under the guise of Medicare) used the Electronic Medical Record systems to steal the joy from medicine. We face rapidly expanding nets of regulations that demand more work but do nothing for patient care.

In the end, we agreed that we love the work despite the administrative hijacking.

When I hear American physicians whine, I tell them they can move, quit, go to Direct Patient Care (where the doc gets paid out of the patient’s pocket), keep whining, or just lay back and take it.

The Canadian internist arrived at the same narrow list of choices, and decided to move back home.

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Spinal manipulation and other tools

June 17, 2017

When it helps, it’s ever so nice

And for me, it’s not about price

For the old spinal crunch

Can sure help a bunch

I’ll manipulate, but not more than twice.

 

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 traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

For the most part I approach medicine in a go-by-the-book fashion. But I keep an open mind, and I try to keep more than a passing acquaintance with what has been called “fringe medicine.”

I took a month’s course in acupuncture as a senior in medical school, but it would take decades and much research it to gain anything like acceptance. We now have more evidence to support the treatment of chronic pain with acupuncture than with opioids (also known as narcotics), yet many more docs use the opioids than the needles.

Honey as a cough suppressant has become a mainstream recommendation.

I went to Michigan State, which has an MD school right next to an Osteopathic school. We shared most of the basic science classes in the first two years, and twelve members of my class demanded teaching in osteopathy.  We met for an hour twice a week in a basement, and we practiced on each other.

In fact, I learned spinal manipulation even before I finished premed. You could call the crowd I ran with “nerds” or you could note that we shared information whenever we could.  But I learned how to feel where other people hurt, and I learned how to crunch backs.

At Michigan State they taught me when to and when not to use the technique. I also learned what they called “muscle energy” manipulation; the technique is also known as “push-pull” or “strain-counterstrain.” You can improve range of motion if you move the affected part to the barrier, then have the patient do an isometric contraction away from the barrier.  I use the technique, for example, after prolonged immobilization in a cast renders a limb stiff.  But it also works when spasm limits mobility.

(Properly done the technique is more complicated than I have described. Please do not try it at home.)

When our oldest daughter contemplated medical school, I steered her towards the DO track; those tools come in handy in primary care. And so far this week I have used them several times, making the patients better before they got out the door, and teaching them how to use the tool in the future.

But the power of manipulation must be used with respect.

In another clinic in another town in another country, a while ago a patient came to me with classical back pain. His chiropractor twice had helped a lot but only for a couple of days.  I crunched him twice, with good relief.  But when he came back the third time, I stuck to my guns, and, rather than manipulating his spine, I sent him for a CT scan.  I could not have imagined beforehand the very grim diagnosis.

 

I’m licensed in British Columbia

May 28, 2017

They don’t give out my license on paper

I hope it won’t turn into vapor

For it’s up in the Cloud

And now I’m allowed

To take the next step in this caper.

 

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 then I’ve worked a few times each in Alaska, Nebraska, and Iowa; I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, about to get a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I haven’t written about my progress getting licensure in Canada since October 2015, when I sent my packet to PhysiciansApply.ca. Much has happened since, and the hypothetical start date kept receding like a mirage.  About the beginning of this year, it got fixed at May 29.

With no exceptions, every Canadian I’ve talked to has been polite, friendly, and helpful; if not knowledgeable they knew exactly the person for me to talk to. I suspect that the bewildering regulations frustrate them as much as they frustrated me.

I flew into Vancouver Thursday for the last 2 items: my work permit and my license. I took a risk coming to the airport without the work permit, but I needn’t have worried.  The polite, friendly immigration officer at one point reassured me that there was no way he would send me back, as I had made it my mission to help the people of northern BC, and I had all my documents (about a centimeter thick).  I had budgeted the entire day for the process, but he had me out before 1:00PM, on my way to a nice hotel room, where later I would toss and turn the entire night, wondering what the face-to-face interview with the College of Physicians and Surgeons of British Columbia would be about.

Rural health facilities find recruiting doctors difficult. While a lot of doctors can be happy with their work anywhere, most docs (not me) have spouses who prefer the amenities of bigger cities.  Though, strangely, early on I rejected a couple of opportunities in Vancouver.

Again, I needn’t have given so much energy to the interview process. It went smoothly and professionally.  I learned about the licensing process for BC, the strictness of the rules involved with the time allotment.  And I got to talk about my goals.

American doctors love to hate the Canadian system that American liberals love, and neither knows much about it. I want to find out about it from first-hand experience, and to be able to discuss it intelligently.

And the moose hunting is way better in Northern British Columbia than it is in Iowa.

Thus I found myself Friday morning walking away from a beautiful building in the heart of a vital, bustling, energetic city with my provisional British Columbia medical license not in my backpack but somewhere up in the cloud. The College of Physicians and Surgeons of BC doesn’t give out paper licenses anymore: they send an electronic file.

It felt a little anticlimactic, but any effort stretched over two years with thousands of emails would.

 

 

 

Reverse Snowbirds

October 19, 2016

North we are planning to go

For the experience, not for the dough

If we prefer cold to heat

Can Alaska be beat?

We’ll wait for the dark and the snow.

 

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Yesterday featured a volley of emails and phone calls to Canada.

American liberals love the Canadian medical system; American doctors love to hate the Canadian system. Neither side understands it.  I want to experience it firsthand.  To that end I’ve been working on getting a Canadian license.

Rural areas in both the US and Canada face terrible shortages of medical personnel. Even doctors willing to work in small communities have to overcome enormous hurdles for licensure if they come from out of the country.  In the US, physicians and other skilled workers from other countries bring diversity to the hinterlands.

I wouldn’t bring much diversity to Canada.

After quite a saga, I’ve gotten to the point of talking with a facility in northern British Columbia. They need me, I’d like to work for them, but I have no intention of immigration (though the social fallout from the election could change that).  After I get a formal job offer, the facility needs to file a Labour Market Impaction Application (LMIA) with Immigration.

Yesterday I learned that a realistic time frame for having Immigration review the LMIA and act on it would be six months. I had planned a mid-January start date.

So Bethany and I sat at the table and asked, Where do we want to go?

It took about ten minutes to decide to go back to Alaska, where we have had such wonderful experiences. And, because the window would come smack in the middle of the winter, we decided on the interior, far from the moderating effects of the ocean, where we’ll face cold more intense than Barrow.  Bethany specified she didn’t want to get in a small plane to get there.

I put several items on my original walkabout agenda back in 2010, among them the Veterans’ Administration, because they’ve been so good to me. I let my fingers do the walking through the Internet.

I introduced myself to the clinic manager and asked if she needed any locums. The sunshine in her voice radiated through my cell phone when she said “Yes.”

I specified the agencies I’ve worked with, emailed my CV, and set up a phone interview with the Chief of Staff.

On the phone today I found out that they need me enough to consider working around the lack of authority to make a contract for a locum tenens.

I usually say yes to 6 assignments for every one that actually happens, and I have come to embrace the uncertainty.

Underworked and overpaid

August 30, 2016

The setting in Alaska was pretty

Near eagles and bear’s there’s a city

With specialists plural

You can’t call it rural.

And it paid really well. What a pity.

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

I worked a week in a city in Alaska.

Alaska doesn’t have many cities, but it has more than one.

They put me up in a very nice hotel, walking distance from the workplace.

Medicare pays doctors very poorly in rural areas, so badly that a doctor cannot cover overhead if the practice includes too large a percentage of elderly. So a lot of private practitioners refuse to see new Medicare patients, and some will terminate care on the patient’s 65th birthday.

Massachusetts attacked the problem by making Medicare participation mandatory for licensure. The doctors responded by moving away.

(Canada’s system pays a premium to rural practices, but they still don’t have enough rural doctors.)

So in this particular city one of the larger institutions put together a clinic for the elderly to take the burden off the Emergency Rooms. Salaried physicians see Medicare patients; the clinic depends on grant monies to continue operation.  The model lacks sustainability.

But the docs still need vacations.

I confess I said yes to the job because of ego; I liked the idea that they would fly me to Alaska, and put me up, for a week’s work.  I had hoped to work for a week a month and get in some fishing before my return, and I would have, if paperwork hadn’t moved at a glacial pace and my wife hadn’t come down with a benign brain tumor.

So on a beautiful Monday morning, I got two interviews, a name tag, and a couple of pamphlets by way of orientation, and started to work in a large hospital complex.

My previous experience with their electronic medical record (EMR) system came in handy despite the major differences between versions.

With not much on the schedule, I sat down with the first patient and said, “Tell me about your problem.” I listened without interrupting till the word flow stopped, and said, “Tell me more.”  At the next long pause I asked, “What else?”

With never more than 7 patients on a days’ schedule, I could take a lot of time with each patient. I enjoyed listening to the Alaska pioneer stories.  One 72-year-old male patient gave me permission to write that he had biceps a 16-year-old would envy.

Most of the patients of both genders have hunted, many still hunt, and I enjoyed discussion of moose and caribou weapons.

I could access specialty services, including ER, quickly, but, as easy as it made my job, it didn’t fit with my conception of Alaska as the ultimate in rural experience.

And, for me, rural makes the adventure.

Working On My Canadian License

November 10, 2015

They have no reason to trust,

To verify is certainly just

They’ll get verification

For each certification

And fill out the forms, well, I must.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

After a surprise two-day stint in Pennsylvania, I returned home.  I had a good conversation with a doctor in southern Alaska; I had signed up for a couple of weeks but hadn’t had a phone interview.  At the end of the call, I decided that the frequency of major trauma and cardiac arrests would put the assignment outside my skill set.

I discovered to my horror later in the day that my Advanced Trauma Life Support (ATLS) certification had lapsed 6 months ago, and, without that credential, I couldn’t have accepted the job.

I got on the net and the phone and I located a course in Kansas City, with one opening.  I took it, but, strangely, I’ll have to pay by check.

I also worked on my Canadian application.

I have three web accounts going: one with the British Columbia agency that can put me in touch with facilities needing my services; one which serves as a depot for my credentials; and one responsible for a BC license.

The third account assigned me a user name consisting of a 12 digit number.

I have had to upload a copy of my medical school diploma, my Iowa license, my residency certificate, my board certificate from the American Board of Family Medicine, and certified copies of my passport, along with recent photographs.  Each professional credential required a face sheet and the payment for a Source Verification Request.

Two weeks ago I sent a packet with those papers.  But copying outsized documents like medical school diplomas and board certificates and residency certificates leaves things out, they said, and I would have to resubmit.  Along with the face sheets.  But I could do so electronically.

Confused by parts of the websites, I call frequently.  I talk to polite, professional, helpful, knowledgeable people.  They admit that some parts of the process don’t make sense, and they help me through it.

In the 21st Century, they shouldn’t trust anything I say nor any of my documents; I understand the Source Verification Request business.  I look forward to the time when I can just send my CV and pay an investigation fee.

And I’m not complaining.

My most recent US state license involved my submitting the same information electronically 4 times and by registered mail 3 times.  And the people I dealt with on the phone weren’t nearly as polite as the Canadians.

I Sent My Medical License Application to Canada.

October 7, 2015

A surveyor came to the door.

The design of the questions was poor

Doctors’ treatment gets worse

Regulation’s a curse!

And the EMR is a chore.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

After wrestling with a recalcitrant, truculent printer, I put together a packet to go to PhysiciansApply, a Canadian agency that helps doctors put their credentials into one central place in the system, so that the various provincial licensing boards can access them.

They wanted: notarized copy of passport, a copy of my American Board of Family Practice certificate, a copy of my residency certificate, a copy of my medical school diploma, a copy of my Iowa medical license, and a Certification of Identity.  This last form required 2 passport pictures less than six months old and a Notary stamp.

I understand the need for these documents, especially, from the Canadian point of view, because I’m an International Medical Graduate.  I hope they go through a thorough verification process.

Luckily I live in a small town, where I can get passport pictures at a nearby drugstore and my next door neighbor has a notary credential.

I sent the packet via FedEx.  I have only sent things internationally once before, when I went through a similar procedure for New Zealand 5 years ago.  I had never considered the importance of declaring contents for the purpose of customs.

A survey taker came about two hours later to ask loaded questions about the Affordable Care Act, also known as Obamacare.  He carried an electronic device.  I sat on the glider on the front porch and leveled with him.  In my experience, every time the taxpayers squawk loud enough, the kleptocrats cut meat from the program rather than fat, so that the taxpayers complain louder, the program gets expanded, and the taxes go up.  I think our government spends too much and spends foolishly (and a lot of that has to do with health care).  But I think we should tax the wealthy more and not tax the poor at all.

I also told him about my experience in Denver, talking to doctors at the breaking point.  The Electronic Medical Records keep getting worse, paperwork requirements keep getting worse, reimbursements keep going down, and the ACA failed to bring in tort reform.  I talked about my fears that our medical capital, our primary care physicians, will start leaving the country.  Already, Canada offers better incomes and more protection from medical malpractice suits than the US.  New Zealand has a polite society, a great EMR and no medical malpractice at all (no tort law, for that matter), a lower income for doctors who have found a good work/life balance.  Australia doctors work hard, bill fee-for-service, and make more than American doctors.

And then I told him I had, that very day, sent my application to Canada for a medical license.

I didn’t tell him I had no intention of moving there.  I want to try the system out, and write about it, honestly.

Another road trip, day 1

June 5, 2015

In the car I picked up some calls

As we drove past fields and malls

To make a decision

Without info precision

I requested an ethical stall

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Since then I’ve done a couple of assignments in rural Iowa, and one in western Alaska.

Bethany and I rocketed east at highway speeds.  The crops still too immature to tell soybeans from corn, the fields have acquired a definite green hue, the brown of the dirt still barely visible between the rows.

A call came through the miracle of Bluetooth and car electronics; a colleague had discovered the perfidy of the recruiting agency.  I worked at that venue for a while, we agreed the work, the staff, and the administration make the clinical side enjoyable.  The town itself we found unique, exotic, and fun.  But we also agreed that we don’t want to work with that agency again.

In this country at this time, when a healthcare facility finds a need for a doctor, they turn to an agency.  If the agency successfully recruits a doctor, they get a large fee from the client, from which they pay the doctor (as an independent contractor), get him/her to the gig, put him/her up once they get there, rent a car if necessary, and finance professional liability insurance.   They also vet the candidate.

They deserve money for their services.  However professionalism runs a spectrum amongst recruiters, and, regretfully, among agencies.

I went to New Zealand through the government-financed agency NZLocums.  They took money from neither doctor nor client, and put me onto a couple of really sweet assignments.

Another, private enterprise agency placed locums docs in New Zealand at that time; they took a commission of about 1/3 and, in return, made sure the immigration process went smoothly.

Later in the day, another call came through from Canada.  Like New Zealand, this province has a government-funded agency to help bring in doctors for short-term assignments; they exist on tax dollars rather than commission.  But I’ve been working with a small, private agency that collects a finder’s fee from the client and lets the doctor and the facility negotiate their own contract.

The person I talked to from the government-funded agency expressed a good deal of unhappiness that I would work with the private firm, told me in no uncertain terms that I couldn’t go through both, and tried to pressure me into making a choice immediately.

I declined to do so, but Bethany and I discussed it as we drove.

We reasoned that on the New Zealand analogy we’d face a tradeoff between the two choices: once would probably offer more money and the other would probably offer better service.   But in a game of imperfect and incomplete information, we couldn’t be sure of that tradeoff, nor of the degree of the tradeoff.

But I know that I don’t like the government agency’s rep’s approach;  I found it high-handed and bullying.  And I know that this adventure is not about the money.

We’ve made our decision.