And 8 weeks draw to a close

This gig has come to an end

I noted a gallbladder trend

The blues seem to vanish

While I’m speaking Spanish

Or mixing in Tex-Mex, a blend

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 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I did telemedicine, staffed a COVID-19 clinic in Iowa, worked at the Veterans Administration in South Dakota, held part-time positions close to home, worked 10 weeks in western Pennsylvania, had a 5-month assignment in Northern Iowa, then several months of telemedicine.  I am now in Texas, a big place with a lot of Spanish speakers. 

I rarely sleep well the night before an assignment’s last day, and last night was no exception.

I bicycled in a heavy mist that bordered on a fine rain, not quite enough to dampen either my shirt or the road surface.  I arrived about 10 minutes early.

Three of my 7 morning patients didn’t show, and I had already met 3 of the four who did.  I sent one to ER.  I signed off a form for another, and while I agreed with the patient about a choice of medication, I knew that the dosage required titration that really needed continuity of care.

For one patient I summoned Google Images as an instructional tool, but not from my most common requests: piriformis syndrome, trochanteric bursitis, and DeQuervain’s tenosynovitis.    

My electronic in-box had a refill request, and 6 patients worth of lab work containing no surprises.

After a noon snack in the break room with Bethany, I sold my bicycle to one of the staff.  I demonstrated the pump, helped fit the helmet, adjusted the seat height, and gave a lesson in using the gears. 

Then we went to a popular local destination for art. 

I gave away the archery target and 6 arrows I have been using to another staffer, and returned the borrowed bow to its owner. 

I enjoyed the gig.  I found four cases of B12 deficiency, and 5 cases of thyroid disease, one of them serious.  I went through the stepwise process of identifying gallbladder disease more than a dozen times, and on two occasions had to push for emergency surgery. 

Most my ER referrals went because of chest pain, some others because of serious infection. 

As with every other venue, alcohol and tobacco brought a lot of patients.  Increasing acceptance of marijuana brings an increasing pathology load.

About 20% of my patients preferred Spanish, another 20% came in as English only.  Many work in agriculture. 

The town owes much of its unique mood to the social structure.  The vast majority of people have more than 10 relatives less than 5 miles away. 

Bethany and I talked it over.  Would we want to come back?  We definitely would.  But not during the summer.  As I write this, the mercury is inching to 95 despite cloudy skies. 

Hill country, hummingbirds, and ice cream

The highway made a steep climb

To hills of granite and lime

A cure for the glum

Tiny birds that can hum

And ice cream, a treat that is prime.

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 on-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I did telemedicine, staffed a COVID-19 clinic in Iowa, worked at the Veterans Administration in South Dakota, held part-time positions close to home, worked 10 weeks in western Pennsylvania, had a 5-month assignment in Northern Iowa, then several months of telemedicine.  I am now in Texas, a big place with a lot of Spanish speakers. 

Sunday morning Bethany and I decided to take a drive into the Hill Country. 

Texas is a very large state with 5 distinctly different ecologic zones.  As it turns out, West Texas is not the same as Southwest Texas. 

We traversed the dry, flat plains, then found ourselves on a highway that climbs abruptly into very broken topography.  The flats have plenty of top soil, but granite and limestone make up the hills. 

It reminded me of the way that the northern slope of Casper Mountain, the tip of a finger of the Rockies, drops onto the Wyoming sage flats of the North Platte River flood plain.

No surprise few people call the area home. 

The empty spaces attract tourists, and when those tourists retire, they like to settle where they used to vacation. 

We passed an area with 8-foot fences, and Bethany spotted animals neither of us had seen.  We pulled over and watched.  Later, using Google Images, we found oryx, black buck, and eland.  I think we also saw a Corsican ram, but I’m not sure.  We didn’t brink binoculars.

Ranching here has come to mean less and less cattle but more and more exotic game animals from Africa and Asia, including giraffes.  And while they’re at it, the owners like to manage for trophy whitetail deer. 

On the way back to town we stopped at a village with an ice cream parlor close to the road. 

We took our generous scoops outside and sat in the shade of a visitor center, closed for Sunday.  They take their hummingbirds seriously, with 11 hummingbird feeders placed near the front entrance, near a blooming palmetto, and another plant with red blossoms. 

We ate leisurely and made little noise.  After a while, the hummingbirds came in, up to 5 working the feeders and the blossoms at the same time. 

Then we saw something we’d never seen before: a hummingbird perched on the lip of the feeder, sipping without hovering.  Over the course of a quarter hour the tiny feathered helicopters ignored us more and more.  One chased another away from a feeder with plenty of room for both. 

And when we drove back, the highway dropped out of the hills and out onto the flats, the rocks gave way to farm ground, over less than a hundred meters. 

Maskless with an infant for the first time since COVID

Work has picked up the pace

And I, with no mask on my face,

In a very short while

I got an infant to smile

When my head came into their space.

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 more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota. I currently hold a part-time position in northwest Iowa, reasonably close to home.

My pace of work picked up this week, and I attended 10 patients today, the youngest less than 6 months old. 

For the first time since the start of the pandemic, I looked at an infant without my mask.  It was a joy to use my entire face to smile at a baby who grinned in response, from face to toes.

I used Google Images educationally to explain an earache, a backache, a shoulder injury, and an eye problem. 

The passing months bring more repeat business.  I usually don’t recognize names because I work skillfully and hard to forget them as soon as possible (in order to safeguard privacy).  Because the mask mandate just lifted, I don’t recognize faces, either. 

Fortunately, I make good notes. 

As this continuity of care stretches on I get to see the Parkinsonian patients wake up and the depressed patients come around.  I also see the alcoholics and tobacco addicts struggle.  I frequently remind the staff that perfect people don’t come to see us or work with us.  I push myself harder than anyone away from judging the patients; my reward when I walk out of the clinic is more energy, and incrementally more success with the patients. 

At the end of the day, I went cycling.  I forgot my bike shoes at home, or maybe I figured the weather would be too cold.  But we had temps in the 70s, I have my bicycling shorts and my pump.  My work boots would not clip into my cleats, but that didn’t stop me from going out into a 30 MPH hot south wind, struggling in 2^nd gear for two miles before turning around and rocketing back in top gear.

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My intended return to northern British Columbia hit the snags of multiple committees needing to sequentially approve my reappointment.  I asked for a time frame, and the bureaucracy would give me no more precise an answer than “several months.” 

To use an analogy from fishing, I put my lines back in the water.

While I review nibbles from sites in North Dakota, Alaska, and Pittsburgh, I took the certainty of extending my current position by 6 weeks, through to the end of the year. 

Google images as a diagnostic genre

Google Images gave us a map,

And a place for the patient to tap,

But the name of the nerve

Threw me a curve

But I’m good at using the app.

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 more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota. I currently hold a part-time position in northwest Iowa, reasonably close to home.

The patient came today with a very strange symptom.  I listened without interrupting.   I said, “So if I’ve got it right…” and repeated back the history. 

I had never heard of such a problem, but I went to Google Images, and pulled up a nerve map.  I showed it to the patient, and said, “OK, point to the area of the problem.”

I came up with the name of a superficial nerve I don’t think I ever learned during neuroanatomy in medical school. 

I called the specialist, a doc a good 10 years younger than me.  He had never heard of that nerve, either.  But he muttered to his office staff then returned to me and said, “Just send the patient over.”

Which I did. 

Contrast is still the essence of meaning, and the ease of the interaction made me think about an experience earlier this week when two specialists successfully dodged a referral.  I ended up wasting 45 minutes till a Family Practice doctor ended the problem, but the episode left me thinking.

Every generation of physicians accuses the next generation of not wanting to work. 

My father got his training at a time of different expectations:  medical school, a year of internship, hang out a shingle and work 24/7/365 till age 65, then retire and die 2 days later.  At that time most docs did appendectomies and hernia surgeries on their own patients, and attended them for hospitalizations. 

I think Dad accepted my not doing surgery, but he looked askance at me sharing call with 5 other docs. 

I kept attending my hospital patients till well into this century.  Each passing year finds fewer docs doing so as the hospitalists take over inpatient care.  In fact, the US (and, less so, Canada) are the only industrialized countries where outpatient doctors take care of hospitalized patients. 

For the younger physicians, hospital avoidance ranks as a quality of life matter; a full service doctor cannot ever hope to achieve a work-life balance, because taking call effectively doubles the number of hours of vigilance, emotional unavailability, and temporal undependability for the family.

Yet these two things will not change:  Sick people want to get better, and they don’t want to be surrounded by strangers. 

Literally, “More.”

The talk I like gently to prod,

With my eyebrows, my smile and nod

I don’t like abrupt

So I don’t interrupt

Today, my smile was broad. 

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 more travel and adventures in temporary positions in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.  Since the pandemic started, I did 10 months of telemedicine in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, and worked as a contractor for the Veterans Administration in South Dakota.  Recently returned from a family visit to Israel, I currently hold a part-time position in northwest Iowa, reasonably close to home.

The average physician interrupts the patient 17 seconds into the visit.  I try to work against that trend.  I say something like, “How can I help?” or “What brings you here?”  or “Tell me about your (ankle, rash, sore throat, etc.,etc.).  I take notes and I wait till they quit talking.  I gently encourage them to continue by using my eyebrows and by nodding.  When they stop, I say, “Tell me more.”

Today the patient said, “More.”

I didn’t get it, and his pandemic mask hid what was probably a mischievous smile.  So I nodded and said, “More.”

He said, “More.”  Then I got it, and I laughed out loud. 

I have been using the same interview techniques for 30 years.  Today, for the first time, the patient took the command literally. 

I complimented him.

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I took care of 5 patients in the morning and 5 in the afternoon.  One I had met before.  The youngest was 3, the oldest over 80.  Two with back pain, five others with disorders in the extremities, and three for women’s health problems.  I used Google images twice. 

When I was overworking myself in private practice, the ideal clinic day had 36 patients; 4 less brought paranoia, and I risked my sanity if I tried to get in 4 more.  At the time, I worked 84 hours a week.  If one full time equivalent (FTE) means 40 hours a week, I became, effectively, 2.1 FTEs.  Now that I work 3 days one week and 4 days the next, I constitute .7 FTEs.  So that the ratio of patients I used to see, to patients I see now corresponds to the drop in number of hours:  2.1/.7=36/12. 

I like to say I did not retire in 2010, but in fact my decision to bring sanity back to my life reduced the healthcare work force by 1.4 FTEs. 

Too many doctors worked too many hours for too many years.  The pandemic brought shocking amounts of death to our colleagues, patients, and coworkers, and, as a group, we started to wonder why we push ourselves so hard.

And a lot of us decided to stop pushing.