Posts Tagged ‘EMR’

Computers increasing chaos: it’s their job

October 23, 2018

Computers that make your work slow
Ignore the proper work flow
Despite lots of cash
Sometimes they crash
Leaving you nowhere to go.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time. Any identifiable patient information has been included with permission.
Yesterday our office manager came to me with the news that the electronic medical record (EMR) system would be offline for my weekend on call. I’ll be able to access the prescription history but not the record of the clinical encounters. I would have to take legible hand-written notes on the yellow ER encounter form.
I vastly prefer keyboarding.
Today I worked walk-ins for the morning. Traffic came light. Mostly I saw the consequences of trying to ignore reality. Though only fewer than 18% of Canadians smoke, smokers constitute 80% of my clinical load. Because smokers tend to drink and drinkers tend to smoke and both tend to use marijuana, the diseases that my patients bring me reflect that magic triad.
After the lunch break I returned to clinic with a crashed EMR. One person’s normal attempt to enter normal data the normal way put in a thousand times more data than the memory could handle, leaving an area the size of France without computer access to health records.
Computers applied to incompletely understood tasks increase, rather than decrease, confusion, thus the introduction of the EMR has literally wrought chaos. Canada, like the US, continues a disconnect between purchasers, users, and generators of computer medical systems. No wonder that the system evokes whispered curses throughout the day.
Fewer here than in the States, though, because the US medical system has allowed administrators, insurers, and data miners to hijack the systems at the cost of physician usability.
Still, work flow has adapted to the computer, and, in its absence, work slowed.
The staffers could use a separate program and data base to print out a patient’s prescriptions for the last year, which helped a lot, as most people came seeking refills.
Between patients, I generated a word processing document, and started typing hasty notes. After I finished with the last patient I went back and neatened things up.
In the end, I had a system I could apply to my ER call. I can take hasty, idiosyncratic handwritten notes, and later return to my keyboard to generate a typed, coherent document, which later can be transferred to the EMR.
I found it a lot simpler to dictate a note in front of the patient. But that was last century.

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Permit, license, insurance, and a contract with the Queen

October 7, 2018

I ended up feeling so keen

For three things, together they mean

I no longer lurk,

But I can come out to work

After my contract I sign with the Queen.

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, my 50th High School reunion, and a 4-month assignment in northwest Iowa, I have returned to Canada.  Any identifiable patient information has been included with permission.

Monday morning I strolled over to the clinic, marveling at my first snowfall of the year.

I had submitted my work permit electronically to the College of Physicians and Surgeons of British Columbia (CPSBC), which they required before reactivating my license.

I got my new passwords arranged. I’ve done 18 new electronic medical record (EMR) systems in the last 4 years, and, having been away from this one for the summer, I spent the morning practicing.  Mickey Mouse’s name turns up as an imaginary patient in a surprising number of EMRs, including this one.  I entered the diagnosis of felinophobia (fear of cats), and practiced ordering prescriptions, lab, and x-rays. I strolled around the hospital and greeted staffers.

I checked my email every 15 minutes for a reply from the College.

I walked back to the hotel for lunch and a nap. Still unlicensed, I returned to the facility.

By the end of clinic hours boredom set in. One of my colleagues called the College on my behalf.

Tuesday came as a replay. Clicking the REFRESH button every 15 minutes doesn’t count as exercise, and by noon I had started to ache from inactivity.

And I didn’t have cases to talk to my colleagues about. I missed being one of the cool kids who has stuff to talk about.

In the late afternoon my email lit up with notification of license reactivation, but I also had the chance to talk with the College about the possibility getting full licensure, making it return more flexible and shorter assignments possible.

I get my professional liability insurance through the Canadian Medical Protective Association (CMPA), based in Ottawa, 2 time zones to the East. So I called them at 6:30 Wednesday morning (8:30 their time), and by 6:35AM I had insurance.

At 8:00AM I strode into the clinic, grinning. In front of witnesses I signed my contract with Her Majesty, the Queen of England, and started into work.

I took care of my first patient of my return before the official start of clinic hours. I got permission to write about the problem, Eustachian tube dysfunction: the pressure in the ears which follows a cold or allergies and for which no effective medication exists. (Insurance rarely covers the only effective treatment, the EarPopper, a device that “pops” the ear, and costs over $300).

PTSD, chronic med refills, adult immunizations, and discussion of complicated endocrine investigations should not come to walk-in clinic. But they did.  At about 10:00AM I had a patient with a true urologic emergency, when I was running and hour late.

The day didn’t get less frantic after that, and I missed lunch.

I vastly preferred the action of the jam-packed day to the boredom that preceded it. And, at the end, I had cases to talk about, just like the cool kids.

 

The Summer in Review

October 1, 2018

The months I spent here were 4

And I thought as I walked out the door

Of the esprit we displayed

And the tractor parade

And how I might come back later for more.

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, my 50th High School reunion, I just finished a 4-month assignment in northwest Iowa.  Any identifiable patient information has been included with permission

I spent the last 4 months in Iowa farm country. Agriculture dominates the town’s economy.  The local subculture has biases against tobacco, alcohol, drugs, and infidelity, and for hard physical work with personal integrity.  Thus my patient population included a lot of very spry folk in their 70s, 80s, and 90s.

I attended several in those age groups with Workman’s Compensation injuries.

I identified Parkinson’s disease in more than a dozen patients, and over the course of the summer saw them improve as I gradually increased their doses of carbidopa/levodopa (trade name, Sinemet).

Four different patients presented with various symptoms which turned out to be hypothyroidism. Some I made better.  But I left before the mandatory six week wait for hypothyroid follow up.

I suspect vitamin B12 deficiency in anyone with neurologic problems. Five such patients had low B12 levels.  Several had borderline levels, and when I did the confirmatory tests of methylmalonic acid and homocysteine I found disease that needed treatment.

I approached several cases of heart failure with the relatively new combination of ACE inhibitor and beta blocker.

Nobody made an inappropriate request for a scheduled drug, a tribute to the tiny medical community and the doc who preceded me.

A number of patients came in with confusing, dramatic neurologic symptoms looking like stroke but resolving when treated for infection and dehydration.

The hospital CEO, a nurse by training, has great leadership skills and no fear of getting her hands dirty. She did a fantastic job with difficult IV starts. When a staffer fell ill unexpectedly, she cooked and served supper to the inpatients.

Such leadership quality echoes throughout the organization. The clinic manager keeps the staff pulling the wagon in the right direction.  People work hard here. Lab and x-ray results came back with dizzying speed.

I used the electronic medical record to retrieve data, but I dictated my hospital, clinic, and ER notes. I entered my inpatient orders on paper.  My outpatient nurses entered prescription, lab, and x-ray orders for me.  All in all, I got to concentrate on patient care and not on the computer.  In fact, policy keeps computers out of exam rooms.

Early in the summer, a nurse, the clinic manager and I went on a house call. As we left town on the country road, we pulled up in back of a slow-moving MRI semi.  Eventually, he passed a farmer on his tractor, who turned out to be part of a tractor parade that stretched as far as the eye could see down the road.

It slowed us, but we all enjoyed the experience and talked about it for the rest of the summer.

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.

 

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.