Posts Tagged ‘Parkinson’s’

And sometimes, it’s about me

September 24, 2018

It shouldn’t be all about me

It’s about the people I see.

And the good that I do

The what for the who,

And occasionally, a day that is free.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission

I did nursing home rounds on Thursday.   Patients come to long term care facilities because of long-term problems.  In the absence of cure, the medical profession settles for treatment.  Thus, in general, I find patients don’t have much in the way of future plans there.

My general approach to smoking relies on hope. I ask, “Do you want to still be smoking in 5 years?”  Most smokers say ‘no’.  Nursing home smokers usually shake their heads, grin sheepishly, and say that they hope they live that long.

This particular facility’s specialty caters to a population that develops incurable diseases at a younger age than the general population. Still, I cared for 9 patients.  I had the pleasant surprise of seeing improvement in 6 and being able to trim the med list of 2.

When I started morning rounds my afternoon schedule had 3 patients; when I got back from the nursing home at 11:45AM I had 4. I rather enjoyed the fact that I could squeeze in 5 more unscheduled patients after lunch.

For the second time since I started here in June, I had documentation and other tasks that kept me working till 6:10PM, a far cry from my usual routine 9 years ago. At that time I started at 7:30AM, sprinted till 5:00 or 6:00, and faced an hour or two of documentation after supper.

Between the nursing home and the clinic, I saw 3 improving Parkinson’s patients.

I had one evening call that involved law enforcement. It went well.

Friday morning I came into clinic and signed in to the computer system. I reviewed labs and answered questions until one of the nurses pointed out that my name didn’t appear on the schedule, and I had no patients for the day.

Five minutes later I had the choice of staying with no scheduled patients or taking the day off.

With so much leisure I drove without exceeding the speed limit, between corn fields turning brown and soybean fields mottling from green to yellow, reflecting on my clinic day.

I felt great. I had seen patient improvement, and had fixed the bleeding and the broken.

Yet my work shouldn’t be about me, it should be about the patients, but confidentiality limits what I can write about them.

Still, my day off was about me.

 

 

 

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Not even a pound

August 19, 2018

Here’s a few things I can tell

This fellow has really aged well

He’s past decade 9

And he feels just fine

And his speech is clear as a bell.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

On the brink of leaving for the weekend, I saw one of my many 91-year-old patients.

The town has a lot of people who have aged well; they have maintained physical vigor and mental sharpness beyond threescore and ten. Partly because of genetics; partly because of community brakes on tobacco, alcohol and drugs; and partly because this particular generation has continued hard work since before WWII, I have the honor of caring for people with a perspective on the human condition that only age can give.

Most of these patients take few medications, despite the fact they’re walking around with artificial hips and knees. A lot of them have atrial fibrillation (now in common American parlance as afib, thanks to drug company direct-to-consumer advertising) and high blood pressure, but a lot of them don’t have diabetes, which I attribute to the town getting a lot of collective exercise, mostly in the form of daily chores.  Very few have depression.

Yet I have detected a trend towards the re-emergence of Parkinson’s disease, characterized by tremor and rigidity of movement and thought. When I finished training in 1982, the vast majority of Parkinson’s came from the 1918 influenza epidemic.  I thought Parkinson’s would evaporate with the death of that generation, but in the last 5 years I have noticed one or two elderly per week with the pill-rolling tremor, loss of facial expression, quiet and monotonous speech, shuffling gait with poor arm swing.

So if I mention a vigorous patient, still employed, in his 90s, with no Parkinson’s symptoms, I have released no identifying information, as so many of my patients fit that description.

And if I say I made a surprise diagnosis via CT scan showing a serious but treatable, potentially life threatening problem, I could be describing dozens of patients.

I could mention a marriage of 70 years duration but I might be referring to any one of a number of town inhabitants.

But this particular patient has not gained a pound since he finished high school, a very unique circumstance. He gave his permission to mention it, and the rest, in my blog.

 

Call, Storm, Flood, and Nursing Home Rounds

June 19, 2018

Bad sleep when on call is the norm

Made all the worse by the storm

Far from a dud

It gave us a flood

But incidentally watered the corn.

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.

The call from the ER at 5:00AM didn’t exactly wake me. The thunder did that hours before, and I tried dozing after.  But I never sleep well on call, and the lightning flashes came through my eyelids, strobe lights through a red curtain.

I should have slept well. My clinic day segued directly into ER call at 5:00PM.  One patient, of my generation, came in with a dramatic history, full of the ironic pains that only the power of human love mixed with inevitable human fallibility can bestow.  Stressed people get sick, sick people get stressed, and I needed 21st century technology, from CT scans to telemedicine. In the end, we finished with a mystery, a neurologic conundrum we do not understand but Hollywood loves and misrepresents.

I still have a lingering feeling that I shouldn’t complain when I have a 12-hour day; earlier this decade I had harder 38-hour days in much more hostile environments, and I kept going.

Still I could have used another couple of hours between the sheets. At the guest house door I looked across the parking lot to the hospital.  With no hat, my white lab coat, more sponge than tarp, offered no protection from the wet.

Damp but not soaked after 50 paces in the rain, I arrived in the ER seconds before the patient.

The presenting problem required much lab and x-ray. I called a fellow ER doc in another city for reality testing.  A subtle but definite physical finding that many would not have noticed complicated the diagnostic picture; a solid, sharp patient with a strong sense of reality clarified it with declarations of no heroics and no surgery. Later, a medically literate relative helped to enforce the decisions.

With the patient tucked into a hospital bed at 7:00 AM, I found the cafeteria had run out of eggs, and I returned through a light rain to the guest house, to make breakfast, and take a too-short nap.

At 9:00AM the clinic manager and I drove 15 miles out to a neighboring town with a nursing home. The cornfields, run emerald riot with perfect temperature and generous rains, had low spots turned to streams and rapids by 6 inches of precipitation in 3 hours.

In the course of the morning I cared for 10 patients. I stopped 4 medications, and started 2 but left orders to stop 3 more.  I had the honor of attending 3 people who had survived the 1918 influenza epidemic. I ordered lots of lab, with little hope of more than a 10% pick-up rate.

I look forward to my next visit, when I’ll be able to see the effects of adjusting some neurologic meds, and I’ll get to talk some more to alert, sharp people born before the Depression.

I hope I get to their age with their faculties.

Sense of humor restored

January 25, 2018

 

Thinks of all the calls that I dial

And the round trips I make by the mile

And the hours on hold

Can leave my humor just cold

But it got restored with the sight of a smile.

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, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I go out of my way to keep a sense of humor. But I’m only human.

I had 8 patients on the morning clinic schedule. I cured the first patient of the morning and sent him on his way.  I returned to a clipboard with 4 sheets of redundancy inherent in a government-based workman’s compensation case.

About 11:00AM nurses told me of an arriving ambulance. By that time I had 5 undictated charts.

The hundred paces to the ER disappeared rapidly under my shoes. I took the history, ordered the CT scan and some blood work, and quick-stepped back to the clinic.  I knew I faced a serious, complicated case which would require a transfer and demanded prompt action.  I finished the last three morning patients and retreated to the break room to listen to the drug rep pitch very expensive asthma drugs and bolt Chinese food.

At 12:45PM I returned to ER just as the patient got back from CT. I finished the history and physical, and awaited the radiologist’s call.

I started with a call to the transfer operator, and the basic clinical picture. Then to the hospitalist, who accepted the transfer.  I started typing up the history and physical and was 75% finished when the hospitalist called back, clarifying some historical details.  Is the patient OK for MRI?

Trips back and forth from my work area to the ER. Calls to a specialist in Minneapolis.  Holding for 10 minutes at a time, while patients waited in the clinic and the piles of unfinished documentation fermented.

No, the specialist said, not a candidate for MRI.

On hold for another 10 minutes with the hospitalist. Do not send patient without speaking with neurosurgeon.

Twenty minutes later the neurosurgeon, dithered for 5 minutes and refused the transfer, and recommended Mayo clinic.

I considered how badly things could go during the hours necessary to get to Rochester.

The nurses recommended a competing Sioux Falls hospital. I announced that my sense of humor was weakening.

Another 5 minutes on hold. The hospitalist accepted the transfer graciously.

I gave the history and physical last-minute revisions to reflect the past two hours of clinical and clerical actions.

With the paperwork all packaged, I went back to the clinic. After 3 hours of the drama, irony, and frustration inherent in trying to be two places at once; after all the tension built into a system of inefficiencies dedicated not to patient care but to the cash flow generated thereby; after literal miles of fast walking hospital hallways, I stepped into the exam room.

The patient whom I started on Parkinson’s medication last week beamed at me when I walked in. The very small doses of a very old drug had done their job; the patient (who gave permission to write more than I have) bloomed.  Now the smile went all the way to the eyes, the speech had music, and the expressions danced on the face.

In less time than it took to shake hands, my sense of humor returned.

Yes, emergency work brings me challenging cases, but I do not want to give up the satisfaction and gratification that comes with patient follow-up.

Finishing early=playing hookey

March 22, 2017

The morning went just a bit slow

And I left with an hour to go                                              

But with the time I had freed

I got in some read

And enlarged the stuff that I know

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.

Last night Bethany and I had the chance to tell my story to a housemate. Coming up to my 60th birthday I knew if I didn’t slow down I’d burn out.  But I had a one-year, 30 mile non-compete clause.  That’s when I went to Barrow, Alaska, the northernmost place in the US.

Bethany recounted the time I called her to say that I had put in 63 hours that week, but I had time for the gym, playing my sax, participating in a jazz group, recreational reading and writing, socializing and watching TV. I initially attributed the extra time to commute reduction and other factors inherent in living in a small community, but then I applied the same criteria to what I’d been doing in private practice and came up with a conservative estimate of 84 hours a week, not counting obstetrics work.

Nowadays, any work week shorter than 60 hours feels like vacation. And when I walk into the clinic on Mondays, my steps bounce and I grin because I love the work.

I love it passionately up to about 50 hours, and after that my enjoyment starts to decay.

And I think my patients can tell when I get excited about a diagnosis. And when the patient makes my day, I tell them so.

Since I got here I’ve been able to radically help about a dozen patients with either Parkinson’s (involving tremor and stiffness) or PMR, polymyalgia rheumatic (an inflammation of the arteries).

But as influenza season wanes, so does the patient flow. This morning I had no inpatients at all.  Of my two scheduled morning patients, the first one showed on time at 9:00 and the second at 9:30.

I used the hours to read up on PMR . It overlaps with giant cell arteritis (GCA) and temporal arteritis (TA).  Because it comes in clusters, some authorities think it might be viral, and, indeed, if a biopsy of the temporal artery (which runs from right in front of the ear up into the scalp on the side of the head) shows TA, 3 times out of 4 it has the chickenpox virus in it.

Bethany met me for lunch.

In the afternoon I did some more work on my Canada license. I read up on Parkinson’s disease.  I saw 4 patients and finished their documentations.  Throughout the clinic, calm and low patient flow prevailed.  I got permission to leave at 430PM.  Bethany picked me up outside the front entrance, with a stiff March breeze blowing.  She took one look at me.  “Feel like you’re playing hookey?”  she asked.

I nodded. I had only worked 9 hours.

Six clinical triumphs and a tornado

March 17, 2017

I had me a wonderful day

I was keeping the blindness at bay

And I helped stop the shakes

Oh, the difference it makes!

To start steroids without a delay.

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.

I can’t write about particular patients but I can write about clinical trends.

Sometimes I suspect Parkinson’s in the first 60 seconds after I meet a patient. I note a shuffling gait with arms that don’t swing, a face with limited movement, and a quiet voice lacking in music.  After the patient finishes their concerns,  I ask about shrinking handwriting size and loss of sense of smell.  Then, if the patient lacks the characteristic resting tremor, I’ll hold the patient’s hand.  If I feel the muscles between the thumb and forefinger quivering, I strongly suspect the disease.

No single sign or symptom serves as a gold standard. Without a lab test for Parkinson’s, the diagnosis frequently relies on response to the medication Sinemet, (levodopa and carbidopa).

Parkinson’s always progresses, but the rate varies. No matter what stage I find the patient in, I tell them that we have no medication that will slow disease progression, but we have a whole sequence of drugs for the symptoms.  Most elect to try the meds, a few don’t.

I love seeing a person in the hour or two after their first Sinemet dose, especially if I find the family close at hand. It really deserves the term, awakening, the title of the Oliver Sachs book and Robin Williams movie about the development of the drug.

I have picked up more than one case per week here.

I’m also finding an inordinate number of people with polymyalgia rheumatica (PMR), also called giant cell arteritis or temporal arteritis. For unknown reasons, worse with advancing age, occasionally a person’s body will attack the arterial lining with very large immune cells.  As a result, people feel terrible, lose strength in their shoulders and hips, and get severe morning stiffness lasting more than an hour.  The symptoms can sneak up over the course of months, or ambush over the course of days.  I ask if their jaw gets tired while chewing.  I feel the arteries over the temples; once in a while I feel hot, ropey spots on the scalp, where the blood vessel pulses .  We use two non-specific blood tests, the C-reactive protein (CRP) and the erythrocyte sedimentation rate (sed rate or ESR), which help make the diagnosis.  The conclusive test is the temporal artery biopsy, but only if it’s positive, which it never is.

Blindness ranks as the most feared complication of the untreated PMR; the artery that supplies the retina can clot off. Thus if I have strong suspicion I start steroid therapy promptly.  A quick response helps make the diagnosis.

Last Tuesday I had the wonderful experience of seeing more than one Parkinson’s patient and more than one PMR patient in their initial positive response to therapy.   Bethany picked me up at the hospital, and in the time it took for me to walk out the front door and get into the car the sky darkened so fast that the street lights came on.  As we drove to the gym I started to recount my day full of successes, but halfway there our phones interrupted with the announcement of a tornado warning.  We continued on, but the noise of the hail drowned out my words.  Three blocks later we arrived at the gym just as the tornado sirens started.

We sat on a bench inside and watched the vacant pool while I finished recounting my 6 clinical triumphs in one day.

Another EMR, and a Parkinson’s patient improved.

December 19, 2015

A tremor after the Great Flu
Is Parkinson’s, we already knew.
There’s more! Please just wait,
There’s a shuffling gait,
And the facial movements are few.

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. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Towards the end of his life, my father developed Parkinson’s disease, which eventually killed him. Ever since I’ve been alert to the diagnostic clues.

When I started in training, 80% of the Parkinson’s that we saw came in the wake of the Great Influenza of 1918. By the 90’s I could tell you from across the street who had escaped that flu (the spry) and who hadn’t (the slow movers). That generation has passed.

When most people think of Parkinson’s, they think of the characteristic “pill-rolling” tremor that goes away when the person moves with intent. But I don’t often see that tremor. I look for facial expression that doesn’t change much, a stiff, shuffling gait, and very small handwriting (micrographia). I listen for monotonous, quiet speech. I inquire about loss of sense of smell (anosmia). I feel the muscles between the thumb and forefinger while I talk tot he patient, which will show the beginnings of a resting tremor long before it becomes visible.

Today a patient made my day with Parkinson’s visibly improved. I had made the diagnosis relatively early. The voice had more music, and the small, involuntary facial and hand movements had returned. Much work remains to fine-tune the medication.

I now have access to the current EMR, NextGen, the 7th EMR I’ve learned since January. I have left off dictating my records like I did in the first two weeks. The computer gets in the way of patient care, but complaining about it does no more good than honking one’s horn in a traffic jam. Nonetheless I worked three unscheduled patients in, and for each one I spent a good deal more time entering data into the computer than I did with the patient. I’ve had lots worse EMRs here in this country (New Zealand’s, MedTech32, stands as a shining ray of hope that we could have a good system), but I have had better, too. It doesn’t stick very much. When I run into a click-and-wait, it doesn’t last more than 20 seconds. Sign on takes less than 3 minutes. But it has design flaws. The button to sign off sits in the top left corner right next to the button used to clear one patient’s chart and move to another. Every drug for every patient comes with a warning, mostly frivolous, but a lot like the boy who cried wolf.

The clinic won’t have it much longer, Cerner will replace it in February.

Another road trip 8: diagnosing in public

June 15, 2015

I can write about things that I see

In public, where the viewing is free

The many, the few,

With no interview

It’s observation, that is the key.

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. I spent the winter in Nome, Alaska, and I just finished an assignment in rural Iowa. Right now I’m working in suburban Pennsylvania, combining work with a family visit.

Confidentiality applies to my patient population; it doesn’t have anything to do with what I can observe in public.

In 1977, when I was junior medical student, I went out for a walk with my first-year family practice resident roommate in Saginaw, Michigan.  We walked past a man with coarse features, a very broad nose and heavy jaw, and outlandishly heavy bones over his eyes.  “Acromegaly?” I asked after we’d past him, referring to a pituitary tumor that starts in adulthood, after the growth plates have fused.  He concurred.

I never stop being a doctor; Even before I had a license, I diagnosed based on observation.

A couple of months ago I sat next to a friend, waiting to get dismissed from jury duty.  I looked down at his right hand, and saw the muscles between the thumb and the forefinger twitching; the medical term, fasciculations, don’t care the evocative quality of “bag of worms.”  I asked if he had Parkinson’s.

Today, my skills kicked in full force at a social gathering.

The bug eyes of Grave’s disease are easy to spot.  The thyroid lump that some people have in the lower part of the front of the neck, goiter, sometimes goes with it.

I saw two cases of scoliosis.  In the crowd I spotted the moon face and “buffalo hump” (enlargement of the fat pad between the top of the back and the bottom of the neck) that signals Cushing’s, from too much steroids (whether made by the body or taken for other problems.)  I could diagnose autism in the young man who rocked and didn’t make any eye contact at all.  From one woman’s rolling gait I could tell she’d had a failed hip replacement.  Several of the elderly showed early osteoporosis.  Several men showed testosterone deficiency by their prematurely narrowed shoulders.

When a person looks at the floor, moves slowly, and dresses in muted colors, I don’t have to do an interview to diagnose depression.

An extraordinarily tall young woman with very long, thin fingers showed all the signs of Marfan’s syndrome; her male relative at 6’8” probably had the same problem, but I didn’t get a chance to see his hands.

I heard the whistle at the end of the cough that tells me that person has asthma.

When another person sneezed three times in a row, I didn’t even have to turn around to diagnose allergic rhinitis.

And after one day’s unemployment…

October 26, 2014

I drove a half-hour away
I had a great clinical day
Oh, what a tonic,
I ignored the electronic
And dictated what I had to say.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I did two short assignments in Petersburg, Alaska. On Sept 2, I turned in my 30 days’ notice.

On Monday this week I drove to Anthon, Iowa for a day of locum tenens work.

Over the weekend, in different social situations, two people approached me for medical advice, mostly having to do with medical care by other docs. For one I later wrote an email to the family, using physical examination buzzwords, expressing my concerns, and, hopefully, getting the patient into a neurologist in a timely fashion.

I made a phone call for the other patient, leaving a voice mail for their other doctor that I wasn’t officially on the case, I had observed certain things, and if the patient took Zoloft and Prozac, perhaps lorazepam could be discontinued?

Monday I left home early for Anthon, a quiet, prosperous but very small farm town. I’ll be working here from time to time for the next couple of months, in the complicated aftermath of a rural doctor’s personal tragedy.

The patient demographics stand in stark contrast to the Community Health Center. Most patients have insurance or jobs or are retired. No one has an accent. I did not see a single patient with major psychiatric illness all day.

Alcoholism, regretfully, stalks the clinical landscape as ruthlessly as everywhere. I applied my recently acquired Motivational Interviewing skills to the situation, and got at least a couple of people to think hard about their lifestyles. At one point, having gotten the initial three minutes of history, I asked very specific questions about the family history and got accused of being a psychic.

The ravages of past tobacco abuse permeated the day. I got the chance to interview one patient about experiences during World War II, and what it was like to grow up on a farm in the 20’s.

I said, as I have said before, “Weight loss in 21st century Iowa is NOT NORMAL and whatever else is wrong with you we have to investigate,”

I prescribed trazodone for depression, chronic pain, insomnia, and appetite loss, noting that the young doctor knows 20 drugs that will treat a disease but the old doctor knows one drug that will treat 20 diseases.

For the second time since I left the Community Health Center, the possibility of Parkinson’s came up.

I ate a leisurely lunch with the staff in the clinic’s tiny lunch room. We finished at 3:15, and I drove back to Sioux City.

I passed the whole day without getting behind in my documentation. The management spared me the learning curve of an apparently very bad Electronic Medical Record system, and I got to dictate my notes. Like in the old days when we had paper charts.

Notes from a smaller conference

November 14, 2013

The conference seemed rather small

A hundred and sixty was all

I picked through the fluff

And brought back some stuff

And we’re all taking way too much call.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego, and a trip to Mexico for our daughter’s wedding.  I’m in Denver now picking up more CME.

As the older, balding male white-haired docs, my generation, lecture about transformation of the American Health Care System, the younger docs, mostly female, no gray hair, file in with their coffees.  The young primarily work for someone else, these lecturers work private practice, fee for service. Except for one who just started working for the govt.  But the guys at the podium attack the problem from a logical, systemic approach.

The whole conference amounts to 160 people and the intellectual intimacy makes up for the lack of world-famous speakers.

When interest lags, the subtle sounds of electronic devices accumulate.  From the back of the room I see screens showing recreational, non-topic displays.

In the hallways and the lounges the practicing docs pass the students.  It’s not that they seem so young or naive, it’s that they seem energetic and passionate.  The phrase dilapidated, meaning literally to have polish removed, comes to mind when I look at the older physicians.

In a lecture on sinusitis, the doctor next to me falls asleep.  His face shows the stress of too many life-and-death decisions made in the middle of the night, the slings and arrows of healing without the healing balm of sleep for the healer.  I want to fall asleep, too.

In the evening I find my right rear tire low and I inflate it at a service station, but in the morning the tire gauge reveals pressure loss.  I pass a leisurely hour in the tire center and avoid horrendous traffic to arrive two hours late.  I have missed two lectures but neither topic interests me.  The first lecturer I listen to goes long because the next lecturer arrives late. He got stuck rounding by difficult cases.

The speech speed of two lecturers trumps intelligibility; twenty minutes into each talk the attendees start to whisper to each other about it, and the recreational screens light up again.  I suspect inappropriate pharmacologic use but I don’t say so.

I quit OB as my 60th birthday present to myself, in 2010, and I have no intention of making a comeback.  So I skip the day’s last lecture on prenatal care.  But I stop to chat with an ER doc and an OB/GYN next to the depleted snack table.  Conversation soon turns to Colorado’s legalization of recreational marijuana, and we start volleying data back and forth.  Children who show up in ER after getting into the now legal brownies and cookies never go to ICU and never die from the toxicity.  Too much marijuana causes terrible vomiting in the cannabis hyperemesis syndrome.  Those who toke before driving having more car accidents and fatalities than those who drink.  We fired facts back and forth like this in undergrad and med school instead of coming to blows, now we try to inform rather than convince.

Between lectures, consistent themes from the docs revolve around the amount of time that the EMR demands; we’re all spending more hours with the computer and less with the patient.

A professor emeritus lectures on William Osler, the premier physician of the last century.  The speaker’s voice is high and doesn’t project well.  He shuffles when he walks on the stage, his arms don’t swing, and the diagnosis of Parkinson’s shows painfully obvious.  But the talk goes well.  The startling news that Gertrude Stein went to med school and washed out in her 4th year brings the proper gasp of amazement, as does the fact that the founding 4 female philanthropists of Johns Hopkins Medical School demanded admission of women.

At the end of a week of lectures, we all agree we work better than we sit.