Posts Tagged ‘residency’

Team Building Experience, Past and Present

July 23, 2017

We played Two Truths and a Lie,

Then had sushi and beer bye and bye

From the end to the start

Team building’s an art

And none of our airplanes could fly.

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.

As I began my second year of residency in Wyoming, the buzz words “Team Building Experience” had just started circulation. Who knows who decided tubing the North Platte would fill that function?  But nobody objected to the idea of leaving town for a day, driving an hour or two, renting truck inner tubes, and getting into a meandering river.

Whoever made the decision hadn’t looked realistically at the time involved. What should have lasted two hours at most turned into a six-hour struggle.  All of us, at one point or another, left the water carrying the tube, swearing never to get back in.  And all of us jumped back in the river.  We all had our reasons, but the most common one turned out to be the sound of rattlesnakes.

I can honestly say no one died, though most of us finished in the gentler stages of hypothermia.

The program wisely decided against further Team Building Exercises for the duration of my tenure. At various times different subgroups held bonding experiences involving large amounts of alcohol and no official sanction.

I don’t know when and if more Team Building Exercises happened.

The office here has Team Building Exercises twice yearly. The clinic closes and a locum takes over the ER.  This time vacations had a couple of the permanent docs absent, and, despite the temporary nature of my assignment, I got invited, too.

We started off with a couple of getting acquainted exercises; one of them called Two Truths and a Lie. We all wrote three sentences on a card, two true and one false.  The group had to figure out the author and to ferret out the lie.

I wrote, “My first college major was Music Theory and Composition. I was an Olympic hopeful in Archery.  I spent 4 nights in jail.”  More people believed I’d been a top athlete (false) than I’d been a composer (true).  But everyone found the idea I’d spent time behind bars plausible, and wanted to know why.  They couldn’t understand what Illegal Pedestrian meant.  I explained it was an archaic Kansas expression meaning Male with a Ponytail.

We went on to build airplanes using nothing other than 3 boxes of aluminum foil. We broke into pairs, sat back to back, and had one person describe a picture to the other person so as to reproduce it.

The last game involved trying to grab an unfolded red napkin from the back of the belt from as many others as possible. I decided to abstain more because of my back and ankles than my age.

After sushi and beer we sat around and chatted and relaxed, something we don’t get to do often.

At the end we thanked our office manager for putting together a great day.

It beat the heck out of inner tubes, rivers, and rattlesnakes.


Badly kept residency records, and Canadian license

November 17, 2015

On the list I’m making the checks,

I sent for my scores from the FLEX.

There’s loads of email

But the process could fail

On the training of the feminine sex.

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 working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I find myself in the process of applying for a Canadian license, specifically for British Columbia.

I want to experience the Canadian system first hand, and compare it to the realities of the current US system.  Then I want to write about it.

That Canada has a national electronic credential depository called makes sense.  I suppose I should have looked more carefully to find the SHARE DOCUMENTS button.  Today I found it and used it.

I don’t blame them for wanting letters from my employers for the last three years, documenting scope of practice and hours.  But how would that work if I had been self-employed during that time?  Actually, I was self-employed during that time; I got pay checks from the locum tenens agencies but as an independent contractor.  Positive they didn’t want me verifying myself, I sent emails off to the agencies.  All of them.

In the summer of 1979, I took a 3 day examination called the FLEX in downtown Denver, Colorado.  About 250 well-educated doctors came together in a cavernous hall.   All the other tests I’d taken up until then counted for nothing more than practice.  I remember that every 45 minutes or so I would have to put down my pencil and shut my eyes for 30 seconds so that I would start caring about the test again.

The Canadians want the original score from that test, and I suppose I can see their point.  I got that task done with a brief Internet search and a credit card outlay of $70.

The licensing process may very well fail on the faded records from my residency.  I had 18 weeks training in Obstetrics, but gynecology didn’t warrant any kind of mention.    And the College of Physicians and Surgeons of British Columbia wants to make sure I had adequate training.  Even though 90% of what I learned then is now incomplete, hopelessly out of date, or just plain wrong.

I spent a long morning on the phone and at the computer, making calls, leaving voice mails, asking for letters and certifications.  Without exception, the Canadians I talked to were polite, friendly, professional, and well-trained.  Their gentle reassurance carried the message that things would be fine, and my license will happen.

I keep an open mind.  If this adventure doesn’t work out, something else will.

I lunched with a colleague who works ER.  I picked his brain for stories of real major trauma.  While we talked about medications, management, techniques and tools, we couldn’t escape the discussion of drama, irony, and tragedy in the face of human bodies damaged by the inevitable truth of physical laws.


Cocaine, nosebleeds, and snakebites: lessons learned in a hurry and not forgotten.

January 30, 2011

Is cocaine the thing that you need,

When it comes to a nose that would bleed?

     Would some other med

    Do the same job instead?

It depends on the books that you read.

I did my residency in Wyoming.  Thirty years ago, I had a license and when I had a free weekend I could work where doctors needed help.  Most places paid fifteen dollars an hour; a seventy-two hour weekend could generate a lot of cash for a young man who had just finished twenty-one years of student poverty.  I soon found that the value of the learning experience exceeded the importance of the money.

In a large state with very few people, before the Internet, I found the pressure of dealing with medical problems outside my experience stimulated me to read, learn, and retain. 

Once, the ER where I was moonlighting got a call about a person who’d been bitten by a snake and would arrive within five minutes.  I had never seen a case of snakebite, but I went to the bookshelf, pulled down Rosen’s two volume Emergency Medicine, and read as fast as I could.  I looked up; no patient, but I had another minute before arrival.  I pulled down Harrison’s Principles of Internal Medicine and read what it had to say about snakebite.  The patient now three minutes late, I took a breath and started plowing through the books at hand.  Twenty minutes later, amazed at how much I’d learned in so short a time, I went to lunch.  The patient never arrived.

When confronted with a frightening nosebleed, Emergency Medicine provided me with a chapter that shines as a paragon of what medical writing should be: a review of the anatomy and physiology, elements of history and physical, proven techniques, and pitfalls, in a concise ten pages.

I faced an epidemic of nosebleeds at the Indian Health Service hospital where I worked fresh out of residency.  I could never determine if my hospital alone or if the area IHS hospitals in general had had their supplies of cocaine removed, nor for what reason.  I knew, for sure, that when I was confronted with the only legitimate use of the medication, nosebleeds, or epistaxis, I couldn’t get my hands on the drug of choice. 

We made do with 2% Lidocaine with epinephrine.  For a year and a half I saw a minimum of two major nosebleeds a week.  Most were the common variety, where the bleeding comes from the front part of the nose, but we also saw the terrifying bleeding from the back part of the nose.  I remember calling up the consultant in the big city at the other end of the highway and saying, “The patient has my best anterior (front) and posterior (back) nose packing job and he’s still bleeding, I’m afraid you’re going to end up ligating (tying off) his external carotid artery.”

“Nah,” he replied, “I haven’t had to do that for ten years.”

He called me the next day and said, “I had to tie off the external carotid.”

My experience with nose bleeds has stood me in good stead ever since, and yesterday I took care of two patients with that problem.  For one, I simply pinched the soft part of the nose shut for five minutes, and the bleeding stopped.  When I looked at the middle part of the nose, I found diffuse redness. 

The dry air in Barrow gets worse in the winter, and noses desiccate and bleed; most of those patients don’t need anything more than a little bit of Vaseline a couple of times a day.

When I looked at the other patient I found a snake-like varicose vein, the origin of the bleeding, about the length of an eyelash.  Numbing the area the way I’d learned in New Mexico, I touched bleeder with a silver nitrate stick for three seconds.  The nitric acid from the stick created a burn, and the vein stopped functioning as a blood vessel. It won’t bleed again.

It hurt like the dickens.  The Lidocaine hadn’t done its job as anesthetic, not like cocaine.

Road Trip 2: Chicago

November 19, 2010

My daughter’s the third generation

She’s had enough education

     To make a diagnosis

     Infer a prognosis

And legally prescribe medication

My father did two years of medical school at University of Missouri and transferred to Harvard.  His Barnes internship gave him one day a month off.  He finished residency in Pittsburgh, and when I was six we landed in Denver for his American Heart Fellowship; he went into cardiology. 

I wrestled with my career choice for years but, unlike my father, I didn’t battle racist admissions policies. Family practice internship and residency meant a mere 100 hours per week.

My daughter, Jesse, a third generation physician, didn’t hesitate to choose medicine.  She had to learn a great deal more during her med school years than either her father or grandfather.  Halfway through residency now, in theory her work week stops at 80 hours (reality differs).

I stopped to see her in Chicago to visit her after an easy day’s drive.

She looks good; she carries herself with confidence and personal strength.  We had a great time talking about cases and patients and the meaning of medicine in the larger scheme of things. 

Nostalgia can lead one to a quagmire; in medicine it risks a journey to a swamp at a toxic waste dump.  Medical care now beats any medical care of the past.  Even if the hours look shorter, medical education get more difficult every year because every year the body of knowledge expands.

I hope but can’t prove that doctors who work sustainable hours will function as doctors more years than ones who don’t.

Society, the world, and medicine have changed since my father carried his microscope into the histology lab in 1948.  I had that microscope refurbished in 1975.  A fun toy, but microscopy skills add little to a practicing physician’s ability to take care of patients. 

We talked about cases and the front-line reality of life.  Every disease carries a human cost and the impact ripples outwards from the patient to the family and the workplace and the society.

She told me about syphilis’s resurgence in Chicago.  I told her how it always started with a chancre (a soft ulcer at the site of infection) when I began med school, but ten years later it rarely did.  She talked about her disappointment at the delivery she had attended the day before, when the breech presentation necessitated C-section.  I observed that when I started private practice in ’87 we sometimes delivered breech babies vaginally (and got some pretty beat-up babies) but by 1989 we’d stopped.

If medical office paperwork doesn’t flow functionally, it will flow dysfunctionally, I told her; this I have learned on my walkabout.  

Her ten-doctor office runs with one nurse and five Medical Assistants, which amazed me.

We went out to eat with her boyfriend (also a Family Practice resident); over Pad Thai and sashimi I got to tell stories about bring up my daughters, liberally sprinkled with observations about thyroid disease and vitamin D.  I watched vigilance exact its toll while he ate, and his OB patient labored; he kept waiting for his beeper to go off.

Doctors will always pay a price for being doctors, tradeoffs are inevitable.

Advising a potential doctor after a good day in the clinic

October 28, 2010

I said to a friend of a friend,
Consider the time that you’ll spend
    And the cash you’ll be burning
    For medical learning
And the terms of the Federal lend

I take care of patients and I cannot write identifying information. They are male or female or confused; they do or they don’t work, they are or they aren’t students or teachers or either or neither or both; some drink to excess; many smoke; each is a part of a family unit and has a social context. They all have feelings; the adults all have sexuality. Each has urges to evil and good in various strengths and directed with differing degrees of mastery.

Today I saw patients for colds, coughs, pink eye, sports physicals, sore throats, urine infections, STD’s, hives, ankle sprains, ringworm, and well child checks.

One patient’s family includes three generations of jockeys, one of whom rode the Kentucky Derby three times (I have permission to include that information in this blog).

My patients bore Polish, Hispanic, Irish, Scots, Czech, English and Indian last names; some had mixed Native American facial features.

One parent and child interrupted each other constantly despite a great deal of apparent love.

I gave advice about nicotine, caffeine, alcohol, trampolines, foot odor, ear wax, seat belts, sleep, exercise and diet.

One person, betrayed by a lover, wept.

Two families were affected by alcoholism.

The clinic today opened at noon and we went till eight.

When I got back from work I called a friend of a friend, actively considering a medical career. No matter what you think medicine is, I said, it will not be that when you finish your training; it will have morphed into something we cannot even imagine. No career holds more honor, few have more job security. These things will not change: people will get sick, sick people want to get well and they do not want to see unfamiliar faces; healers will hold a high place in society and they will be fed.

Becoming a doctor requires an investment of two years for premed, four years for med school, and three years for residency; the money invested pales in comparison to the time. Government programs that finance the education demand payback on a year-for-a-year basis, and pay a fraction of what could be earned in private practice.

I had a National Health Service Corps scholarship to medical school; they paid tuition, books, and a stipend.  I worked in the Indian Health Service three years past my obligation because my time with the Navajo enriched my life beyond measure.  When I left my income doubled every six months for a year.

Medical school changes the person who enters. Someone who seeks only riches will either drop out of the program or will change their attitude; the same can be said for those motivated purely by altruism.

The doctor who doesn’t put first things first in his or her own life won’t last in the profession. The doctor who neglects physical needs, such as eating, sleeping, human relations, and medical care, will burn out.

Pick a specialty, I said, based on what you’re good at and what you love. Don’t go into something because you admire a particular specialist.

Life is full of tradeoffs: travelling light is expensive

May 30, 2010

I’m working too hard to get packed

My complacence is coming up cracked.

     It’s a bit of a fight

     But I can’t travel light

To Barrow for months, that’s a fact.

When I started moonlighting in 1980 I learned to pack fast and travel light.  When I would get off of work on Friday afternoon, I’d go home, pack for a three-day trip, and jump in the car.  I never exceeded the speed limits like most Wyoming drivers, but I knew I wouldn’t start getting paid till I arrived. 

In residency at the time,  I learned more and earned more moonlighting than I did during the program proper.  Fifteen dollars an hour, compared to what I’d earned in the past, seemed a very large amount of money.  I came to view material goods in terms of what a weekend of work could buy.

I had to hurry to both ways.  After a few trips, I learned how to pack efficiently.

I can ready myself for most vacations in less than a half hour without trying. 

A hunting trip takes a lot more time because one must bring a wide variety of clothing.

Today, I spent most of the afternoon and evening packing. 

I have never packed for a two month trip before.  It may turn into a three-month trip with possible hunting at the end. 

In medical school when I did externships I didn’t pack for one month trips so much as I moved, and every time I moved, I moved fewer things.

Now part of the establishment, my clothes reflect my position.  I have proper business attire for 8 days.  An Alaska destanation demands cold weather gear.  Because I’m going to Barrow I can’t rely on availability of consumer goods when I arrive.

Travel in the information age demands a computer, a camera, a Palm, and iPod and all the cords and impedimenta that go along with them.

Previously proud of traveling light, I look at my luggage pile with embarrassment.

One cannot go to discover new adventures without leaving home; one must weigh mobility against cost.

Life is full of tradeoffs.