Posts Tagged ‘EMR’

Hardware, software, and chairware

June 24, 2018

A problem is found, tell me where?

Is a problem that’s not the software

I said to IT

Perhaps it is me.

Is the answer to be found in the chair?

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, and 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.

Eight years ago I took a course for doctors who want to be writers. Don’t use the word suddenly, they said, and never write, “All hell broke loose.”

I suppose all writing has rules, yet I haven’t figured out all the rules for effective blogging.

But I find myself enjoying this gig. A small hospital is an efficient hospital; one doesn’t waste a lot of steps.  Consider the context:  a functional Iowa town just big enough to have a hospital.  In two weeks I’ve dealt two marijuana users, and no drug seekers.  Every urine drug screen has come back clean.  Fewer than 10% of the patients smoke.

And I have time to spend with the patients. I listen attentively, I don’t interrupt.  I get to dictate my progress notes, and I can enter my hospital inpatient orders on paper.

I haven’t figured out how to use the Emergency Room EMR, not quite the same system as the inpatient program. I just couldn’t get it to turn on.

Today the Information Technology person asked me to show her the problem; I signed on and got a nice border on an otherwise blank screen.

“Is it the hardware?” I asked

She shook her head.

“The software?”

Headshake.

“The chairware?”

She looked at me, left eyebrow crowding the right.

“You know, the person in the chair?”

She burst out laughing, and told me she’d get back to me.

Despite cool, rainy weather, the clinic overheated. We got out the fans.  I sweated.  For the first time I realized that my large flat screen monitor produces a huge amount of heat.

The morning went at a reasonable pace. Online research, signing my dictations, reviewing labs.  Then at 11:00, suddenly, all hell broke loose.  The surgeon and the nephrologist each asked me for consultations.  The radiologist called from Orange City.  The neurologist called from Sioux City.  Two non-English speakers turned out to have a much more complicated clinical picture than we could have imagined.

I worked through lunch; the nurses and I did not get a chance to eat.

In the course of 4 hours I read 4 electrocardiograms, ordered 4 sets of labs and admitted 2 patients. I accommodated a walk-in.

I worked hard to replace my fluids lost to sweat.

And just as suddenly, things went quiet at 4:15PM. I finished with the two hospitalized patients at 5:00PM on the dot.  Food became my next priority.

 

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New Job, First Week

June 13, 2018

I laughed, and said with a snort

In the square of the town there’s a court

You could call the town small

There isn’t a mall

And friendly comes by the quart

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, and 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 saw a distressing number of serious pneumonia cases during my first week on the new job. Each patient presented differently, each brought in a life story from a family context.  And each challenged me in a different way.

We have exceptional pneumonia vaccines that don’t prevent pneumonia nearly as well as they prevent death from pneumonia.

In the last 40 years the disease has changed a good deal, and we’ve reduced the death rate, but not nearly enough.

The history and physical make the diagnosis more than anything. We listen for a crackling sound as the patient breathes in, but mostly we listen to the patient’s narrative.  Still we get blood counts, blood cultures, chest x-rays, and occasionally CAT scans.  A new blood test, pro-calcitonin, helps a lot but hasn’t made an appearance in any facility where I’ve worked.

I disappointed several patients by not finding ear wax.

I have acquired a minimalist approach to medication at this stage in my career, an approach that many of my patient appreciate. I especially enjoy stopping statins, a class of cholesterol-lowering drugs that can stop heart attacks and strokes, but will not prevent a first one after the age of 65.

The facility has a small staff and a small footprint. I counted 36 steps from my office to the ER, and 6 steps from ER to radiology.

I get a steep discount on meals, reasonable cooking served in reasonable portions.

Various licensing details have insulated me from the worst of the Electronic Medical Record (EMR) headaches, and I get to dictate my notes.

A small parking lot separates my accommodations from the ER; a landline assures good communications in the unlikely event of a sound night’s sleep.

I haven’t run into marijuana problems yet. Smokers constituted a surprisingly small proportion of the patients.  Not surprisingly, binge drinkers here, as everywhere, have difficulty with insight.

The facility has a gym, a CAT scanner, anesthesia, and a surgery program. I worked with two of the nurses here during my days in private practice, and I established a relationship with the radiologist during one of my other assignments.

Most of the referral traffic will go to Sioux City, where I still know many consultants.

And there’s an absolutely first class pizzeria about 20 minutes away.

 

Paper Order Joys and Outpatient Dictation

June 7, 2018

If it helps to make a decision

We like a CAT scan’s precision

It sure made my day

When in truth I could say

It looks like you’ve dodged an incision.

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, and 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 arrived 15 minutes early for a brand-new gig. I started the usual orientation: meeting a lot of people whose names I forget and shuffling around a confusing geographic set-up.

No one expects me to remember everything the first day, but much like any other human learning endeavor, one has to find a starting point,

The facility has three EMRs, one each for the hospital, the clinic and the ER. The ER and hospital systems communicate with and resemble each other, but do not qualify as twins.  And I’ve used the hospital system before, in Nome and in western Nebraska.

The outpatient system, however, looks like nothing I’ve ever seen.

For reasons I don’t completely understand, my schedule keeps changing, and I covered an outlying clinic in the afternoon.

I cared for 5 patients, including 2 children, both of whom I mesmerized with my yoyo. I managed to not increase anybody’s prescription burden, recommending only agents available over-the-counter.

Not a single patient came to the ER that night, yet the vigilance of call kept me up.

I only attended 8 outpatients and an inpatient the next day, yet high-stakes clinical material dominated the landscape. I sent two patients to the CT scanner down the hall.  Surprisingly, the results swayed the decision-making process in both cases.  Neither went to surgery nor to inpatient.

A different patient became my first admission to the hospital. The wonderful nurses gave me the choice of writing my orders or entering them into the computer system.  Grinning, I took the hand-written option, and later watched a new-hire nurse struggling through an unintuitive system.

The glitch that prevents me from using the outpatient system for entering lab and x-ray orders or for electronic prescribing continues to defy resolution. The management here lets me write my orders on plain paper and have the nurse enter them into the computer. I dictate my notes.

And I finished on time. For whatever reasons, for the time being I can enjoy slow patient flows.

The patients have already started asking if I’ll move here. Forever.  I thank them, but I decline; Bethany and I still have more adventures to look forward to.

 

 

The First week back in Canada

December 10, 2017

Oh, the joys of that 12th vitamin B

A low makes me dance round in glee

For without scalpel or knife

I can save someone’s life

And the med costs a very small fee.

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. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

Though scheduled for orientation on Friday, I remembered a good deal of the electronic medical record (EMR), and started in with walk-in patients at 10:00AM. By the end of the day, I’d attended 11 people, as good as my best 8 hour clinic day during my most recent month in Alaska.  Patient flow goes very well here, documentation comes easily.

I carry the title locum tenens, which means that I’m a substitute or a temp, and only the night before did my name fall onto the schedule. Yet I knew 4 of the patients I took care of.

Monday started a very good week. I enjoy patient care, but I know that seeing too many patients in too short a time brings too much stress.  I saw a decent number of patients, rarely ran more than 10 minutes late, got lunch every day, and finished my documentation before 5:30 PM.

Filling in for two docs, at one point I had more than a thousand lab results to sign off.

An unusual percentage of the alcoholics I saw recognized the problem, and an unusual number of smokers had already decided to quit. Although, in fairness, an almost identical number of smokers had no interest in stopping.

I took call on Thursday to Friday morning. I slept poorly as much from the emergency at 3:00AM as from zigzagging time zones.

Friday more than half my patients represented repeat business. The clerical staff informed me that when people learned of my impending return, they waited to schedule with me.

Three of those patients had vitamin B12 deficiency. One of them gave me permission to write about the thrill I get from running the right test at the right time and finding that diagnosis.  I don’t often get to save a patient’s life, and, with B12 deficiency, I get to do it for pennies a day.

B12 deficiency most commonly presents as fatigue. In the past I started the investigation on the basis of depression, anemia, numbness, gait disturbance, erectile dysfunction, ADHD, and dementia.

In other clinics, management has discouraged me from ordering B12 assays in the Emergency Room or Urgent Care contexts. Yet, finding a result in my lab queue with that critical L beside the number brings me disproportionate joy and gives me a goofy grin for the rest of the day.

Which is why I prefer positions where vitamin B12 measurements are appropriate.

6 afternoon patients and an evening power failure.

October 22, 2017

With a light do you send out a scout

To see what the problem’s about?

For it gets pretty dark

And the prospects are stark

Up here when the power goes out.

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. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

On my first Friday back in the Arctic, I got to talk with a Native about village life.  After getting through the medical agenda, I asked about fishing.

The village in question right now does it a lot.  And, with freeze up coming, the Natives are working the set nets.  Soon the caribou migration will start.

But the whaling grabbed my attention.  We talked about a village that brought in their entire quota of 10 bowheads last spring; in times past the villagers sometimes had to make do with as few as 4.  In the process, we talked about making the bombs necessary for the complicated harpoon that the Natives use.

***

I had the thrill of making two people better before they left.  One I helped with massage and spinal manipulation, one with an exercise I saw on YouTube.  “YouTube?”  the patient exclaimed, “You mean I could be a doctor from YouTube?”

I said, “You want to learn to put in a chest tube or do a cricothyrotomy?  Go to YouTube.”  And, in fact, you can find instructions on almost any procedure.

***

Still learning, or relearning, the Electronic Medical Record system here, I only had 6 patients scheduled for the day, 2 in the morning and 4 in the afternoon.  I’m just getting the hang of sending the prescription to the pharmacy before the patient leaves, and finishing the remaining documentation later.

The docs here meet with staffers for morning report, much like we did during my time in Barrow (now called Utqiavik).  Shortly before the meeting started, I realized I’d brought the wrong cell phone, the one with no local signal.  Yet, wonder of wonders, I had two bars of service and updated email.  I texted Bethany to not text me on either phone, attributing the miracle to sun spot activity.  She didn’t get the message; I have no idea if solar flares were responsible.

***

We had settled in for the night when the power failed, and moonless Arctic nights have a deep, Stygian darkness.  We have had power failures everywhere we’ve gone, and for the most part we can laugh it off as part of the adventure.  But our all-electric housing has no alternative to combat the cold, and while I searched out flashlights and head lamps (a total of five) I started to worry about making it through the night.  While the hospital has emergency power and we have long underwear, here we lack the cold weather sleeping bags and tents residing comfortably in our basement in Iowa.

The words power outage take on new meaning in an unforgiving climate.

Thursday last week I started to work

June 4, 2017

I took care of the patients I got

I gave a couple a shot

But for one of the rest

I’ll need quite the test.

The work just hit the spot.

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.

I started the day early, and lingered over breakfast while I watched a YouTube video about the underlying geology of northern British Columbia. The clash of tectonic plates has resulted in a coastal mountain range separated from the west edge of the Canadian Rockies by a central valley, everywhere scarred by the violence of glaciers.  All in all, I’m experiencing lovely scenery in an orderly, safe community where the children can walk unaccompanied to school.

Now 4 days into my Canadian adventure, I came to work this morning prepared for orientation in MOIS, the Electronic Medical Record (EMR) system (and my 15th in 30 months), but, alas, still lacking password sign on.

I took care of the latest, and hopefully last, couple of glitches in my bona fides. I did some email.  At the very last part of the morning, I started EMR training, which I followed by playing with the test patient named Mickey Mouse.  I knew immediately his birthdate was off, but finding citalopram (an antidepressant) on his med list came as no surprise.

When I came back from lunch, I had my first patient on my schedule.

I immediately fell back into my 3 question rhythm: Tell me about your problem.  Tell me more.  What else?

Though just starting on the learning curve for the EMR, and though I needed EMR coaching 5 times for 6 patients, this system seems easier to learn than most. Or maybe I have learned how to learn.

Two patients needed injections, three patients’ problems centered on their right leg. The last patient of the day turned out to be more complicated than anyone could have imagined, and will need follow-up and work-up.

To my surprise, the doctors here do their own injections, a job in the States uniformly delegated to RNs, LPNs, and, sometimes, Certified Medical Assistants. I have had to learn injection techniques on myself, as I take vitamin B12 shots into the muscle monthly, and Enbrel injections into the fat just under the skin every 5 days.

I took care of a total of 6 patients in the afternoon. Still clumsy with the EMR, I didn’t finish until 5:00PM, an hour after the clinic closed, but still a good deal earlier than what I’ve been doing for most of the last 40 years.

I thoroughly enjoyed myself.

 

 

First day working in Clarinda

February 13, 2017

My plans sure had a great bump

With an executive order from Trump

Now I’ve got me a scribe,

Which is close to a bribe

And gave my orientation a jump.

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.

A facility has a doc out temporarily for unplanned health reasons. They do not expect the planned replacement to recover from injuries sustained in an accident in time to help out.

The Executive Order freezing federal hiring used such vague wording that a VA facility couldn’t give me a start date. Thus, at the end of 2 weeks planned vacation, I started looking for work.  One of my favorite agencies found me a spot in southwest Iowa, hard by the Missouri border.

This placement represents a success of the concept of locum tenens, temporary doctor placement.

Yesterday the clinic manager gave us a tour of town. We learned that all the patient lifts in the country come from Lyle manufacturing.  The other big plant here makes ball bearings.  Glenn Miller grew up here, the town sports a museum in his honor and has well-attended band competitions every year.  Clarinda Academy, a last-chance facility for troubled youth, sits close to a minimum security prison and a mothballed state mental health hospital.

At orientation today I toured the hospital, got my ID badge, met dozens of friendly people whose names I promptly forgot, and got trained on the Electronic Medical Record, CPSI.

Perhaps I’ve learned so many (14 in 27 months) that they all look the same, but in less than an hour, it started to make sense.

The patients love the internist I’m filling in for, and don’t particularly want to see a stranger. After a 4 hour orientation and a 1 hour lunch, I saw 3 patients.

None of them smoked, none sought prescription drugs for recreational uses. All employed, all motivated to get better.   Each got at least one prescription, all got advice on lifestyle changes, mostly about the caloric content of beverages: at 140 calories each, one serving of milk, juice, soda, or beer per day comes to 14 pounds per year.

A hundred years ago a junior doctor working under a more experienced physician kept the medical records and in return received teaching. To this day, a medical student or resident rotating through a specialty service refers to the experience as a clerkship.

With legal and financial pressures pushing doctors’ notes longer and longer, many physicians have turned to scribes: people who make notes during the face-to-face visit. The doctor gets out on time, sees more patients, and pays more attention to the patient.  Today, I had my first taste of working with a scribe, and I liked it.

 

Live like a student now, or live like a student forever.

November 7, 2016

Here’s a puzzle for the bold and the clever

If a dollar’s a lot like a lever

You can be foolish or prudent

To live like a student

For now, or even forever.

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. 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.  After a moose hunt in Canada, I am back on the job in western Iowa.  Any identifiable patient information has been included with permission.

I didn’t get into this business for the money, and I have a strong aversion to debt. I stayed hungry in medical school till I got a National Health Service Corps scholarship: the Feds paid for my tuition and books and sent me a monthly stipend which paid rent and groceries, but not enough for a car.  In return, I promised to work at a designated Medically Underserved Area, a year for a year.  As I had all along intended to work in the Indian Health Service, I mistakenly didn’t view the contract as debt acquisition.  I savor the memory of my IHS days, but I would recommend that course now only with cautions.

Because debt is debt. Our daughter’s med school financial counselor advised her that she could “live like a student now, or live like a student forever.”

Lending institutions then and now approach medical students with loan offers. On a corporate basis, the payoff works well.  Students can borrow money against the future high earnings.  The lenders’ pitch goes something like “Hey, you’re going to make so much money in the future, why suffer through years of poverty?”

Those students who take the bait for 4 years can acquire debts that last for decades. Some get locked into suboptimal job situations.  And some keep borrowing, maintaining a high-dollar lifestyle but without building wealth.

A banker once told me a lot of doctors have a smaller net worth than their monthly Adjusted Gross Income.

Between keeping a simple lifestyle and Bethany’s wise management of our funds, I can afford now to work as much as I want, and keep visiting new places. For the next few weeks we’ll be in western Iowa.

We have a snug apartment attached to an ancillary service building, and we share kitchen and living room space with a medical and a pharmacy student. The building even carries a sign that says ”STUDENT HOUSING.” And living with students brings back memories of my early career.

I started today learning my 13th Electronic Medical Record system in 25 months.  All have major weaknesses, and this one promises a steeper learning curve than most.  I take no comfort in the fact that Corporate plans to replace it in less than a year.

The community turned out larger, more prosperous and energetic than we anticipated, and the hospital itself appears well-organized and well-run. The primary care area’s layout minimizes the time wastage inherent in larger medical operations.

And, for the time being, I don’t mind living like a student again.

 

 

 

Apology and an abnormal thyroid

October 25, 2016

A veteran I might legally be

Does it feel like that?  Not to me

I sure owe a debt

To the Viet Nam vet

Without any PTSD  

 

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. 

I cleared out most of the month to take some holidays, but I accepted a couple of days’ work in a rural clinic not far from home.

I didn’t get formal training on the Electronic Medical Record. It turned out it didn’t take much to get me going.  They let me dictate my notes and they let me work with a nurse who knows her way around.  It doesn’t hurt that I’ve learned 12 new systems in the last 24 months.

I made that observation to a colleague involved in the residency, who noted that our Family Practice residents have to deal with 7 different systems.

The first day I worked in the new venue, I massaged away the headaches of two patients, and helped two others by taking out ear wax. In the evening, I saw three patients in the ER, two of whom required hospitalization and consultation the next day.

The pace of work went well that next day, and I drove home in a reasonable time frame.

Bethany came with me when I returned at the end of last week, driving past corn and soybean fields in the early stages of harvest.

Doctors can take some pretty rough verbal treatment, and an apology first thing in the morning made my day.

I did several pre-op evaluations. In one case, my findings came so markedly unexpected I had to call the surgeon to formulate a plan.

I cared for a Viet Nam combat vet with no Post Traumatic Stress Disorder. I told him how highly I regard the VA.  I see him as a Real Veteran but I don’t see myself that way.  He reassured me that anyone who has to put up with owning a uniform, and having a rank in a system with bad pay and bad management  qualifies as a Real Veteran.  We had a good discussion about emotional resilience and how it plays a big factor in PTSD.  He gave me permission to write about more than I have.

Even if I can’t write about people, I can write about medical conditions. I really like finding abnormal thyroid results.  Because a thyroid gland, either over- or under-active, can cause a lot of different symptoms.  When my thyroid went into overdrive, I could not sleep, I lost weight, I had no inner peace, and I couldn’t sit still.  I know that, sooner or later, my thyroid will quit working and I’ll need to take replacements.  And at the end of the day, the nurse handed me a slip of paper with an abnormal thyroid result, which explained a lot but not all of the patient’s symptoms.

 

 

 

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.