Posts Tagged ‘New Zealand’

After two unemployed months, back at work

April 7, 2018

Of the patients there’s never a lack

I can tell you it’s good to be back

I think that it’s neat

When the patients repeat

And I can see that they’re on the right track.

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, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

Today I cared for 12 patients, 1/3 of whom I had cared for either last summer or in December. Respiratory problems dominated the clinical landscape, but I also saw 3 who came in to find out test results and five who needed prescription refills.

I recognized the first patient and without prompting opened the visit in French. He gave me a heartfelt grin.

I recognized one patient as a New Zealander by his accent. At the end of the visit I got into geographic specifics, and in short order we started talking about Warkworth (pronounced Walkwith), Leigh (pronounced Lee), Matakana, Omaha Beach, the Kauri Museum, Pakiri Beach, and Whangarei (pronounced Fahnga Ray).

Three patients discussed travel to Mexico, either completed or anticipated.

In December I posted about a patient whom I gave the opposite of my usual dietary advice; she returned to see me today. The plan worked, and the problems related to excessive weight loss disappeared.  We discussed favorable labs, and she requested I write about her in more detail.

A quarter of the patients use marijuana regularly. The only smoker wanted to quit.  Nobody admitted to excessive alcohol.

I did yoyo tricks for my one pediatric patient.

The return to work came as a relief after two months without employment. Including those seeking casual medical advice, I averaged less than 3 patients a week since February 1.  Today I fell into the rhythm of my usual questions: tell me about it, tell me more, what else?

News of my Immigration problems circulated here even before I published my last blog post. Patients, staff, doctors, and bystanders commiserated with me.  I pointed out there are few better places to be stuck than Vancouver.  We all agreed if you have to get turned away at a border, none can beat the US-Canada border.

A lot of people, in the clinic, the hotel, and the mall, asked after my wife, Bethany. She made a lot of friends during our last two stays. I got the feeling people missed her as much as they did me.

It was good to be back at work, in a system centered on patients and not cash flow. And it was good to be with a bunch of my colleagues, talking about cases and learning from each other.

At the end of the day, pleasantly tired from the action, but far from exhausted, I stepped out into bright sunshine and temperatures just below freezing. I had finished all my documentation.  I didn’t have to think about anything else but the weekend.

 

 

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Trying to figure out what “call” means

June 21, 2017

When my weekend came to an end

A patient off we did send

With findings so rare

It gave us a scare

And help we needed to mend. 

 

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.

 

People can use the same word and mean different things, different words to mean the same thing, or even the same word in different contexts to mean different things.

Doctors use the term “call” when talking about coverage after hours and on weekends, but what does that word “call” really mean?

In Utgqiavik, the town formerly known as Barrow, it never meant anything other than 12 hours. I have been places where holiday call meant ten times that.  Depending on the location, weekend call might start on Friday or Saturday morning.  Or it could include staffing a Saturday clinic.  Sometimes it meant ER coverage only.  For a couple of decades I had to field calls from nursing homes, patients, ERs and hospital inpatient units as well as obstetrical duties.  For one former employer, if I drew the duty, I could count on sprinting between hospitals to admit patients till midnight, and a minimum of one phone call every 45 minutes requiring critical decision-making.

In New Zealand, when I worked for a North Island outfit, “call” meant staying overnight in the clinic.

On one particularly memorable assignment, it meant nothing other than having my name on a calendar slot. I had protested the marginal cell coverage at my dwelling.  Administration told me not to worry, in the event of a disaster the Sheriff knew where he could find me.

I write this while on weekend call. Sunday morning dawned very early and very clear.

During my 23 years in private practice, the docs wouldn’t talk about how the weekend went until afterwards. The same superstitious factors leading to that custom led to the many Emergency Rooms that banned the “Q word” (quiet).

What does weekend call mean here? Starts at 8:00AM Friday, ends at 8:00AM Monday, followed by a day off.

Now post call, I can say I cared for 3 people who, for one reason or another, didn’t have a chart in the local electronic Medical Record. I never cared for more than 12 people in one 24 hour period.  Several times, on the verge of leaving for the apartment, I asked people on the way in if they had come for emergency services.

At the end, a patient arrived with an extremely rare problem, so serious I called a colleague for help, and ended up riding in the ambulance to the medical center.

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.

Canada, rainbow’s end, and pheasant glass

May 12, 2015

In the evening I dove east in the rain
With a rainbow out over the plain
No matter what you’ve been told
At the end, there’s no gold,
But in fall, we just might have grain.

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. Just back from Nome, Alaska, I’m now in Grundy Center, Iowa.
I drove with the sun at my back, eastwards, from Sioux City towards Grundy Center, across flat farmland dotted with wind turbines. The dramatic clouds in front of me contrasted with the sunshine behind me, clarity against darkness. Bit by bit, a rainbow emerged against the backdrop, first at the north end, then at the south, and finally arched right across the sky.

I could not help but remember our train trip south across New Zealand, between assignments. Seven rainbows graced the skies that rainy day.

I picked New Zealand over Ireland in 2011 because of the medical licensure application. Ireland’s 84-page form brimmed with dense prose, indefinite antecedents and esoteric usage despite nominal English, after a week spent on the first 10 pages I gave it up as a bad bit of work, added it to recycling, and picked up New Zealand’s four-pager, which I completed in an under an hour.

Right now I’m working on a Canadian license. The paperwork so far has been reasonable to the point of unbelievability. In fact, I don’t believe it and I’m waiting for the full weight of bureaucracy to fall across my electronic desktop.

Trish, my recruiter, has guided me with patience and kindness. We mostly talk on her days working at home. In the US, recruiters work for agencies to place physicians where needed; the doc works as an independent contractor. The agency guarantees transportation, professional liability insurance, and housing. I can’t generalize for all Canada, but my recruiter puts doctors together with institutions in need. The professional then negotiates with the employer about rate, insurance, lodging, and transportation. In the end, the Canadian recruiter takes a much smaller piece of the pie. And doctors do their own negotiations.

In the beginning, I had no particular geographic aspirations. I even considered working in Quebec because I speak French (acquired, with Rosetta Stone, last year). Later I realized that the French spelling system with its archaic silent letters would threaten sanity maintenance in a medical environment.

Alberta, Manitoba, and Ontario slipped out of consideration, one by one, for different reasons.
So over the course of the last two months, my recruiter has helped narrow my focus from all of Canada to British Columbia, and I have entered the weird world of international licensure. Each province has its own license authority, just as every state in the Union does, but they have a degree of reciprocity.
Why Canada? Not chasing rainbows. I want to work in the Canadian system, which American doctors love to revile without understanding it. I don’t understand it either; I want to experience it first hand, and write about it. In all fairness, I’ve worked the American system for 33 years and I don’t understand it.

And I have all the rainbows I want, anywhere I go. I came over the crest of a hill, and the north end of the rainbow, always retreating at a fixed distance, shone against the brown and green of the Iowa fields germinating corn in the spring. No pot of gold, no leprechauns, just gleaming yellow, and a moment later, for a thrilling second, the south end of the rainbow popped up out of a gulley.

Then, WHAM, a hen pheasant died on my windshield.

Blog end: I’ve reintegrated

January 16, 2012

I had a great time, it’s a fact

My life had been so out of whack

I flew cross the sea

From Barrow to Leigh

Now I’m home and it’s good to be back.

I received an email from a doc who went walkabout to New Zealand for a good deal longer than I had, and asked me questions about my reintegration.  I asked for permission to post the original missive, but three weeks later haven’t heard back.

I replied: 

It’s interesting that you emailed me six months to the day after I started back into work here in the States, and if it’s OK with you I’ll use your email and this return as a post.

I’ve enjoyed reintegrating to US society and the medical care system.  I’m back doing hospital work, which, strangely, I really enjoy.   I know my consultants on a first-name basis and I like the camaraderie in the hospital.

It helps that I’m working for a Community Health Center.  For a lot of reasons, our patient population gets sicker earlier.  The pathology load weighs heavy on them.  At any one time, half of our twenty to thirty hospital patients also appear on the nephrologists’ list because of chronic renal failure and dialysis.  Usually we have three people in active DT’s and three others in liver failure. 

I have had to get used to the paranoid reality of defensive medicine.  Our patient population has made the transition easier because many have no money and no insurance and hence can’t pay for procedures that probably weren’t needed in the first place.

For those with insurance, I worry that I overuse medical technology.

Getting labs back the same day, like glycohemoglobin and TSH, makes patient management easier, as does having in-house x-ray.  

I liked MedTech32, the electronic medical record (EMR) system that makes documentation so easy throughout New Zealand, and the hardest part of coming home has been dealing with Centricity, whose software engineers remain isolated from any contact with this particular end user; for example, I have to click through five data fields to make a back to work/school slip and I have no way to fix it.  My productivity has gone way down; eleven patients in a morning or afternoon taxes my resources; not that I spend more time with each patient but I spend more time fighting the computer to enter data.  And about half the problems could be fixed easily.

I miss the way I always started on time in New Zealand because I brought my own patients back from the waiting room, and I miss the way the patients (mostly) respected my time.  In my current situation I limit the patients to three problems per visit.

Narcotics seeking remains a problem here as well as everywhere.  I’m building up a reputation in the street-drug community here, just like I did in the South Island, as parsimonious with opiates and benzodiazepines. 

Still, my practice swells with new patients every day.  I like pediatrics, and I find that a new practice attracts young people and young families, even with an old practitioner.

In the long run, most people either fit into the category of wanderers or homebodies, and I am definitely a homebody. 

But man, did I have a great time.

Turning sixty-one on a seven rainbow day

May 8, 2011

We came along way on the train,

Watched the rainbows after the rain,

     Crossed the Strait on a ferry

     It was scenic, yes very,

We saw things you can’t see from a plane.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  After four weeks in Wellsford, on the North Island of New Zealand, I just arrived at my new assignment.

We rolled out of Auckland, heading south through the early morning in one of three damp but modern passenger cars trailing behind a diesel engine and a baggage car.  Outside of New Zealand’s biggest city, the suburbs gave way to pastures, sheep, and vineyards.  Cornfields came so infrequently that they merited remarks.  Two hours from town the train switched to an electric engine.  We climbed to New Zealand’s volcanic plateau to National Park, which was established as the world’s second national park after Yellowstone, out of respect for the Maori who held the area sacred.  Half the passengers had come from Auckland to lunch there, and stayed in the Park railway station café.  During the stop we walked around the built-up administrative center, as far as Highway 1. 

South of the park by a half-hour, we switched crews with the north-bound train. 

Rain fell off-and-on throughout the day, and we stopped counting rainbows at seven.

We napped when we had the inclination, and ate mediocre train food from the café car while we looked over spectacular scenery and astounding engineering.  Bethany refused to look down when we crossed some of the trestles, I don’t blame her, but the sight took my breath taken away.

We pulled into Wellington in the dark, twelve hours after we started, and walked through the rain to the Hotel Ibis.

We remembered the good bed and the quiet room; we forgot the inadequate blackout shades until after we turned out the lights.

Without enough sleep we took a taxi from the hotel to the Interisland Ferry; our driver retired from 25 years as a locomotive engineer to drive cab part-time.

We had no idea the ferry would have eight decks, including a cinema below waterline.   Entranced in a Scrabble game, we left Wellington Harbor behind and passed into Cook Strait between the North and South Islands.  Picton, the ferry port, lies due west of Wellington, the capitol, but the large number of smaller islands requires a twisting course.  Listing to port most of the way, I could perceive sea motion only in the food court at the prow, four stories above the water. 

At the Visitor’s Center, Bethany and I watched the backpackers in their 20’s.  I’m a tourist, too, if I’m honest about it, but I carry a stethoscope.

After a two-hour layover we continued our odyssey on the Naked Bus (just a name).  When Highway 1 didn’t snake treacherously through the hills, it ran peacefully through the flat places, where we saw center-pivot irrigation and large cornfields.  We had gotten used to the seven-to-ten acre vineyards of the Matakana Wine Trail; as section after section of manicured South Island wine grapes passed by the window I remarked that the vintners needed a pipeline more than trucks. 

The country around Nelson lacked the greenery of the North Island.  The round hay bales had thin plastic cylindrical covers, just like Iowa, not like the smaller bales of the North Island swathed in complete envelopes of heavy plastic.

Our course ran along the northeast part of the South Island’s Pacific coast, where deserted black sand beaches separate spectacular breakers from irrationally steep hills dotted with occasional sheep.

We stepped off the bus in Amberley at sunset.  If we’d taken the plane we could have made the same trip in four hours door-to-door, but we would have missed two awestruck days of scenery.  Life is full of trade-offs; we wouldn’t have had a day of rainbows without repeated rain storms. 

I spent my birthday going from one assignment to another; I enjoyed the transition. 

You only turn sixty-one once.

Slowing down: fifty-four, not seventy-two

April 26, 2011

Here’s a fact that I’ve found

This one I’m sure will astound

     It’s just fifty-four

     Hours, no more

But really, I am slowing down

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  On assignment on the North Island of New Zealand, I’m living in an apartment attached to a clinic in Matakana, north of Auckland.

ANZAC day commemorates the Australia-New Zealand Army Corps losses, first in WWI and then in later wars. It’s not my holiday because I’m not a Kiwi, and I volunteered to work the clinic today. This year the coincidence with the Easter weekend gave the country a four consecutive days off.  I tacked my fourteen hours today onto the fourteen I did on Good Friday and the twenty-four I worked the day after.  I worked at a reasonable pace, and got at least one break a day; today I took a morning and afternoon tea break and went out for both lunch and supper.

Yesterday evening I stopped being able to stay awake at 8:00 PM and went to bed; I slept soundly till 4:30.  Breakfast followed shower.  Without the anticipated traffic I arrived twenty-five minutes early.

Holiday business continued; as of 6:00PM I’ve seen twenty patients and done (or not done) phone prescriptions for 4 more.

‘Two patients have studies pending which I hope prove me wrong.

I looked at one patient whose dermatologic problem has failed to clear for nine years, and instantly disagreed with the previous diagnosis, in part because of inadequate response to medication.  I prescribed a skin creme, handed over my card, and requested a post or email if a cure resulted.

I treated six patients non-pharmacologically. 

I lost track of the number I told to quit smoking and drinking.

I made four patients better before they left; I cured one.

I did no defensive medicine.

When I went out to eat I walked down Wellsford’s main street in the rain, glad of my duck-hunting jacket and my cap.  I heard a couple speaking Spanish outside a cafe; I threw six words into their conversation and made them smile.  I wanted to stop and chat, to find out where they were from, and the forces that had acted on them to be here in this place at this time, but I walked on so I wouldn’t breathe their cigarette smoke.

They had left  by the time I returned; the nurse departed at eight and I spent the next two hours on-line researching my next placement.  When I turned out the lights and set the alarm at ten, I had worked fifty-two hours, twenty less than I usually work on Easter weekend. 

Pouring rain lengthened the drive home by twenty percent.  With light traffic, I fought the urge to break the speed limit along the straightaways.  I arrived in Matakana, the town was dark and quiet, and, like me, tired from the long weekend.

The problems of time: crossing the equator, avoiding jet lag, caffeine as an ally, and not celebrating March 11.

March 12, 2011

I messed with my internal clock,

With the advice and support of my doc.

     One late night so fine

    We crossed the Date Line,

And went for an evening walk.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, we’re now in New Zealand.

I didn’t celebrate March 11 this year.

I graduated from medical school on March 11, 1979, and every year the day evokes vivid, euphoric memories, the savor of the occasion lingering with me from the time I awaken till I fall asleep.  I remember the day, and the night that followed, well.  My brother, my father (also a physician) and I went out for Chinese afterwards; my fortune cookie said, “You will have great power over women.  Use it wisely.”

But I didn’t mark the occasion this year because I crossed the International Date Line from March 10 directly to March 12.  Most of the people on the airplane remained fast asleep, but I kept looking up at my TV screen from my Droid/Kindle book.  I watched the icon of the plane cross the line on the map at a 30 degree angle, skipping March 11 without even a feeling of turbulence.

New Zealand has one time zone and two islands. Six o’clock Sunday afternoon in Sioux City happens at the same time as Monday noon in Wellington.  The summer here ends when Iowa’s spring begins; the Vernal Equinox at home corresponds with the New Zealand Autumnal Equinox. 

An eighteen hour time difference boils down to a six-hour time difference for the sake of calculating jet lag.  In the Los Angeles airport we drank Pepsi, ate chocolate, and played Scrabble so we wouldn’t fall asleep once the plane took off.  With consultation and prescription from our doctor, we took eight milligrams of Rozerem (a prescription version of melatonin) and ten milligrams of zalpeplon (a four-hour sleeping pill) eight hours before we anticipated the dawn at our destination.  Shortly prior to our early morning landing we each ingested two hundred milligrams of Provigil (a stay-awake pill for shift workers and jet laggers).

Once we’d overcome the SNAFU at Immigration and cleared Customs, we trudged two kilometers from International to Domestic terminals in Auckland.  The flight from Auckland at the north end of the North Island to Wellington at the south end of the North Island went boring well. 

We fought the natural urge to nap after we showered at the hotel.

Nor did we sleep till after we’d eaten and exercised and the sun had gone down.  By that time we’d wandered around downtown Wellington.

I didn’t have my March 11th celebration this year, and I didn’t miss it.  If all works well, I won’t be jet-lagged when I meet with the New Zealand Medical Counsel tomorrow.

Filling out forms, a disagreeable lifetime pursuit

September 18, 2010

Every day since I left the dorm

I’ve had to fill out the form

     They’re never the same

     Except they ask my name

And how well that I stick to the norm

 In my senior year of high school I got so fed up with filling out forms that I put twenty items on a questionaire, titled it FILL OUT IMMEDIATELY, and left fifty copies at the school’s front desk.  Forty-six forms were filled out.  I don’t like filling out forms, and what goes around comes around.  I think I’m being punished for my prank.  As life goes on, the forms get more frequent and trickier.

I’ve been filling out forms to find new locum tenens jobs.

Even where I am a known quantity with a good reputation, I have to supply the same information.

They all want to know where I’ve worked, where I went to school, where I have licenses, if I have physical or mental problems, if I have alcohol or drug problems, if I’ve ever been convicted of a crime, if I have ever been taken off of Medicare or Medicaid rolls, if I’ve ever been sued, if I’ve ever been refused privileges at a hospital or been disciplined there.

But are the same and the questions are all phrased differently.  “Have you ever been convicted of a misdemeanor or felony in any jurisdiction of the United States or other country?”  is not that same as “Have you ever been convicted of a misdemeanor or felony aside from minor traffic violations?”  I answer the first one with my five parking tickets, my one moving violation, and my conviction of being an illegal pedestrian (I’m not joking).  For the second I can check the No box.

Some ask for the day, month, and year when I started and stopped certain activities, some for the month and year, and some just ask for the year.

They also want copies of my licenses, medical school diploma, and Continuing Medical Education (CME) activities.

I would think that in the twenty-first century checking me electronically would be more reliable than looking at photocopies of paper documents. 

A number of countries would like to import American doctors; one such country’s eighty-seven page query document collection is written so opaquely that even though the official language is nominally English I can’t understand the forms; I’ve been working on them for months and each time I get the jitters.

Today I went down to Staples and got copies made of the certificates which are most asked for: med school diploma, residency certificate, state medical licenses, the details of my legal history, and DEA permit.  I left with five copies of the packet.  I’ll need them. 

I’ve been talking to recruiters for spots in New Zealand, Wyoming, Dubuque, an Indian Reservation and Grand Island.  I’m stoked.

Of course I have to remember that many plans fall through at the last minute.

I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks out I’m having adventures.  To comment on a post, click on the title.