A telemedicine morning

This morning my work was remote

Still, I wore my white coat

So many did sneeze

On account of the trees

The cedar pollen’s like smoke. 

Synopsis: I’m a Family Practitioner from Siux 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 southeast Iowa, worked at the Veterans Administration in South Dakota, held a part-time position close to home, worked 10 weeks in western Pennsylvania, and had a 5-month assignment in Northern Iowa.  I’m doing telemedicine at home again.

I descend the basement stairs before full day and open the shades on the window.  I take a couple of minutes to restart my work computer, pass the two-stage security sign on, check internet speed, microphone and camera. 

Then I look out my window, before the day starts and take my first sip of coffee from a cup brought home from an adventure. 

Having a window at work ranks not only as a status symbol but as a quality of life measure.  I can’t think of another medical niche that would let a doc gaze onto the outside world while attending patients. 

Pennsylvania.  Alaska.  Pennsylvania.  Texas

Male.  Female.  Male.  Male.

First 5 calls all between age 27 and 63.

Bipolar.  Tobacco.  Alcohol.  Cough.  Toothache.  Bipolar.  Rash.  Cough.  Real sinusitis.

Referral to psychiatry.  Motivational interview for smoking.  Tales of drama and irony amplified by hereditary behaviors.  Acupressure.  A problem that needs more care than I can give remotely.

I take a 5-minute break to catch up with the documentation.

Iowa.  Texas.  Iowa.  Alaska.

Two pediatric patients, two adults in their 30s. 

Cough.  Cough.  There is no better cough suppressant than honey, and I talk about beekeepers , their large social networks, real honey and the adulterated product sold in stores.

A patient who says their pharmacist knows me and a chance to show off great pronunciation of a polite word in a language I don’t speak.

Texas.

The mountain cedars of Texas have started to explosively release their pollen.  If you live with those trees for more than 8 years you will be allergic to them.  Fluticasone nasal spray (generic for Flonase).  Zyrtec.  Neti pot. 

Pennsylvania.

Try gravity drainage for your sinuses.  If it works, do it as often as you need, if it doesn’t work the first time, the second time has a 10% chance of working. 

Texas.  Texas.

Sinusitis and tobacco. 

I stretch my legs and throw a handful of peanuts-in-the-shell onto the back patio picnic table.  My coffee has cooled to perfect temperature and it warms and nourishes me. 

Unlike most doctors, I didn’t start drinking coffee till after I’d turned 70 and the pandemic was in full swing.  The coffee cup of the 21^st century holds the equivalent of 3 20^th century cups. 

A chance to use my Spanish and hope I don’t embarrass the Hispanic by speaking the language better.

A 5-minute break to watch the squirrels with the peanuts.  They’ll be back several times later in the day. 

Iowa.  Texas.

Pregnancy complicating medical decision making, opting for the lowest-impact treatment. 

Drama and irony, discovered because I keep my mouth shut and listen, revealing key elements of the patient’s illness. 

Tobacco and alcohol.  Alcohol.  Alcohol and marijuana. Marijuana with no tobacco or alcohol.  Three patients in a row with no intoxicants. 

STI.  Medication refill. 

Calls from school, calls from trucks, 3 calls from minivans, 2 calls from home.

An audio only call.  Strangely, almost all these are for burning with urination.

Calls from public places.

Pink eye.  Respiratory.  Chest pain: go to ER RIGHT NOW. 

My stomach growls. 

I linger with the last patient, and tell a joke in Spanish. 

I change back into my t-shirt and come up the stairs for lunch.  I have the rest of the day ahead of me.

Arguing with my eyes

There is silence that comes with a blink

In a conversation it serves as a link

To 3 second pause

That I use just because

It makes people just stop and think.

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.

While the majority of Americans have received at least one COVID vaccination, most of the people who come to see me have not.   So I address alcohol and tobacco problems, and use similar but not identical techniques for vaccine hesitance. 

First I promise not to argue or make fun, then I ask why the patient hasn’t gotten the safest, most widely tested vaccine in human history. 

When approaching problem alcohol and tobacco, I repeat what the patient says.  With the anti-vaxxers I have trouble keeping a straight face and leaving out sarcasm when the patient says, for example, that the vaccine contains baby feces and might result in an arm growing out of the patient’s head (which one patient said; this pandemic, but not this week).  So I just listen, and I don’t interrupt. 

Today one of those conversations reached epic shortness when the patient said, “Personal choice,” and stopped.  I knew that I had no chance of progress in the absence of ambivalence.  So I blinked and moved on. 

Another patient today gave reasons, but didn’t stop.  And the more patients talk, gesture, and repeat, the more I know they don’t really believe what they say.  So I listen and I give the blank stare and I stop my micro-nod.

Today the patient recognized the technique.  I said, “I promised I wouldn’t argue.”

She said, “You’re arguing with your eyes.”

So I owned it and I asked for and received permission to write it in my blog, as the first time a patient has seen through my technique.  But I succeeded in getting the patient to think.

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Preoperative history and physicals made up the bulk of my work this week, more than half for cataract surgeries, on patients born between the 30s and the 70s. 

This facility gives me 45 minutes for each one, an unspeakable luxury of time.  I revel in listening to answers and letting the patient speak till running out of things to say. 

Some stories have more details than others, but different people want to talk about different things, because every person’s life has different drama. 

Patient might share 2 diseases with me

There’s a problem with the bones of the spine

The x-ray looks awfully like mine

The problem is complicated

Inflammation is implicated

I hope I’m wrong and the patient is fine.

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.

Staffing shortages come for a lot of reasons.  Doctors are burning out and aging; some met their financial goals and re-evaluated their lives when they saw so many friends and colleagues die.  Some had problems with financial viability during the pandemic and decided to step out early.

But the same pandemic that hit the doctors hit the nurses (and the police and the retailers and the service industries, etc., etc.) Thus, lacking staff support, my work week would start on Tuesday. 

A good thing I didn’t have much planned for the day.  The VA called to tell me I qualify for tixagemab/cilgavimab (trade name Evusheld), an injectable medication designed to prevent COVID complications for 6 months.  I had never heard of it.  But I looked into it and decided to take the offer.  I could make the trek to Sioux Falls, and return to my current assignment the next morning without having to drive all the way back to Sioux City. 

I got the injection at the VA’s Infusion Center, the same place where they give cancer chemotherapy.  After a couple of needles, they made me wait for an hour. 

I spent 5 hours driving that day.

On Tuesday fully 1/3 of the patients came in for back pain.  Not just common back pain, but complicated back pain lasting months, going down one leg or the other, and each one had at least one red flag symptom: numbness, weakness, loss of bowel or bladder control, morning stiffness.  Each one met criteria for MRI. 

Normally, 5 lumbar vertebrae separate the rib part of the spinal column from the pelvis.  One of the patients has a transitional 5^th lumbar, with one side fused to the pelvis, and had known it since adolescence (and gave permission to write about it).  I also have the same x-ray finding, which kept me out of Viet Nam and probably saved my life. 

I can hope we don’t also share ankylosing spondylitis, but I have to look for it.

I found another case of vitamin B12 deficiency, and started investigation on 2 other borderline levels. 

I saw 12 patients, ages 16 to 87.  I knew 2 from previous visits.  One had responded to my motivational interview techniques for tobacco (get the patient to first say 3 good things about it, then 3 bad things, repeat in a non-judgmental fashion what they said, then ask, Where does that leave you?).  He happily reported complete cessation. 

Which made my day.

13 patients: alcohol and tobacco rule

Some live with an excess of drink

And before they come to the brink

For sure they can’t count

The number or amount

I just try to get them to think.

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 out0of-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.

Because of travel and internet access problems, some posts are out of order.

I got to work early today and started going through labs; the first test in the queue was a vitamin B12 level of 160.  I grinned.  I know that I can save a life and make the patient feel better for pennies a day.

But I also had 4 patients come up with a high BNP (pro-brain natriuretic peptide), indicating heart failure.  For those with established cardiology connections, I found it easy to send the numbers to docs who know more than I do, for the others I had to keep in mind that full time cardiologists inhabit other towns, and occasionally visit here. 

I attended 13 patients today, aged 15 to 90. 

My fluency with the electronic medical record (EMR) increases daily.  The morning flew past.  I got lab studies back.

An alarming physical finding prompted a discussion with a patient.  My usual approach starts with, “I’m being paid to think of the worst things I can, and I’m good at it.  I can think of some really bad things that aren’t very likely.  How about we don’t go through the list until we know the diagnosis?”  But today, the patient wanted to know the bad things that circulated in my thought process, and I went through them.

One smoker quit last night, another cut down to 2 per day, and 2 more don’t want to quit.  Those trying to quit by cutting down haven’t made the emotional commitment to deal with the most addictive substance on the planet, and I say, “If you quit by cutting down and stay quit for a year, come and find me and I’ll take you out to lunch.”  After thirty years, no one has qualified.  I heard one success story, but years ago I filed it with other urban myths.  Still, stranger things have happened. 

Alcohol destroys the ability to count drinks or remember frequency.  Those who consume large amounts occasionally don’t realize binge drinking constitutes a phase of alcoholism.  I accept the figure the patient gives, I ask for the 3 best and 3 worst things about alcohol, I repeat the patient’s words, and then I say, “Where does that leave you?”  Many bad things already happened because of alcohol, and yet the use continues.  If I leave judgement out of the picture, though, if I can get them to think, I stand a chance of changing their behavior. 

How to put 75% of the physicians out of a job

Perhaps genetic predilection

Could serve for behavior prediction

I’ll make a confession

Like those in my profession

I’m employed because of addictions.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4^th time.  Any identifiable patient information has been included with permission.

Addictive processes have commonalities. People lose count, they lose control, they fail at trying to set limits, the addiction takes priority over health and family, adverse consequences happen but the behavior continues and continues to demand more and more time as use escalates.

Not surprisingly, addictions account for a disproportionate part of my business.

Fewer than 15% of Canadians smoke, but smokers today make up 75% of my patients.

Most drinkers smoke and most smokers drink, and, not surprisingly, most marijuana users also use tobacco and alcohol.

Long ago I quit trying to get substance abusers to admit to a problem. Most of the time I can get them to tell me about the chaos that envelops them.  When we discuss alcohol, marijuana, or meth, they generally make light of the problem, and I ask, “How’s that working out for you?”

I do not contradict the people who say, “Just fine.”

But I frequently try to get the patient to talk about their goals. And then I ask, “How does $8,000 dollars going every year to tobacco, alcohol, and weed fit in with your plans?”

Those techniques I got from a program called Motivational Interviewing, and, thanks to the wonders of the Internet, it has become available to anyone with a computer. It allows a person to capitalize on someone else’s ambivalence.

I do not expect to see the impact of Motivational Interviewing immediately; doing locum tenens I rarely see the impact at all.

But last week over the course of 2 days, 6 of my patients declared intentions to get clean and sober. Three asked to be sent for counseling, and two have already started going to meetings.

Each one of them comes from a back story of betrayal and abuse, loaded with drama and irony and promises made and broken. If they keep on the path of recovery, they will discover that weaknesses can be strengths and strengths can be weaknesses, depending on application and timing.

I hope this trend continues and spreads. Doing away with addictions could potentially put ¾ of the doctors out of business.

I hope I live long enough to see it happen.

Lower blood pressure with deep breathing

It’s a technique, and I don’t mean to brag

But when the smoker lights the first fag

And breathes deep and slow

Though the smoke is the foe

They’re champs at that very first drag.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I see a good number of people with high blood pressure, some better controlled than others. If the pressure is too high, I repeat the reading.  A second round of measurement less than 5 minutes after the first will give a falsely elevated reading.

Most of those with hypertension (a blood pressure greater than 140/90) smoke tobacco and drink more than healthy amounts of alcohol. I point out to the smokers that they have a valuable tool, that they didn’t realize they had.

I was still working for the Indian Health Service when I had a conversation with the worst nicotine addict I ever met. She had quit 4 packs per day about 10 years prior.  Half the relaxation of the cigarette, she said, is the deep breathing technique that goes to taking the first drag.  Every meditation system in the world stresses the deep breathing that all smokers have taught themselves.

Breathing can change blood pressure a lot. The FDA approved a device to teach people to slow their breathing down; the studies showed it safe and effective for blood pressure control.

So I tell the patient to pretend they’re taking the first puff of the day, to breathe slow and deep, and I breathe with them.

I repeat the blood pressure measurement after 6 deep, slow breaths, and almost always the top number drops by 30 points and the bottom by 15, good enough for most people. Whether the improvement is adequate or inadequate, I tell the patient to breathe slow and deep for 20 minutes a day, whether in one chunk or twenty.  For those current smokers, I point out that they could get half the calming effect of tobacco just by doing the breathing exercise that they already know how to do.

+=+=+=

I had call last night. With light traffic in the ER I managed to get back to the hotel early, but I got called back at 10.

As far north as we are, I walked to the hospital with the setting sun in my eyes. Forty-five minutes later, I walked back in the twilight, thinking that I should have brought the bear spray with me.  I crossed the highway with literally not a single vehicle moving.

Tagalog, flu, and a staff meeting

The patients still suffer the flu,

And I know just what I can do

Though to prevent what they’ve got

We’ve a pretty good shot

But I’m hoping for some drugs that are new.

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.

Most sick people want to get well, and even more don’t want to be around strangers. I’m filling in for a doc whose patients love her.   They won’t come in until they feel sick or worried enough, and I haven’t had time to build a reputation in the community.

I attended one patient every half-hour from 9:00 till 11:00. I ran 5 lab tests, and ordered one x-ray.  Half the patients got prescriptions, half of them got advice because pharmacologic management would have been a good deal more dangerous than helpful.  With the unseasonably warm weather, I advised two to get over the counter Flonase for allergies. Another patient got a simple 5-day prescription that may very well save a life.  One patient has me puzzled and awaiting labs.

I exhausted my very meager Tagalog vocabulary on one person (who gave me permission to write this), prompting my patient to ask me if I’d lived in the Philippines. I explained that the most educated immigrant minority in this country are the Philippino, with a disproportionate number of doctors, nurses, and pharmacists.  Of course I’ve had colleagues from that country.  And, inexplicably, on the North Slope of Alaska, the Tagalog speakers dominate the taxicab business..

Three patients smoked; for each one I held my forefingers 18 inches apart and said, “On a scale of 1 to 10, how ready are you to quit smoking?” No matter what number they came up with, I asked, “Why not 2?” but had to explain that the doctors had already told them the bad things about tobacco, and I wanted the patient to tell the doctor something good about it.  One patient shook her head and said, “You’re good.”  I had to admit that I’d gotten the technique from an educational CD.

We had our monthly med staff meeting from 12:30 to 2:00. They announced my successful vetting (in the trade, we call it credentialing).   We went over changes in the Emergency Medical System (EMS), and talked about criteria for blood transfusions.

The flu came up briefly; the annual epidemic started about 3 weeks ago. It’s weakening but it’s still going.

I had no patients on the schedule after 2:00, and I started reading the handbook that HR gave me. I had two patients after 430, finishing at 6:00 sharp.  I walked out with all my work done.

Sports physicals and good horses

Out here they have nothing to hide

They think it’s important to ride

The unified force

Comes down to a horse

They’re cowboys and cowgirls, bona fide.

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Thursday the construction noise had become intolerable. I put on my shooting muffs, and stepped out the side door.  The worker operated an electric jackhammer, not a drill, detaching a concrete lip from the foundation.  I waited till he had hacked off a chunk, stopped his machine, and repositioned.

“Excuse me,” I said, “Um, any idea how much longer you’re going to be?”

“Almost done, probably by lunch,” he said.

“Do you have hearing protection?”

“Yeah, “he said, “In the truck.”

“Take it from me,” I said, “If you want to be able to hear the voice of your grandchildren, protect your ears.”

I had a productive day, between outpatient and inpatient I attended 14 people.

Sports physicals, required by school districts, don’t save lives and don’t prevent injuries. On average, less than once every two years I detect a problem during a pre-participation exam that I can do something about.  Still, the visit goes quickly, and I get to educate the kids.  As the athlete sits on the exam table I ask what sports.

Here in western Nebraska a lot of the students start their list with rodeo. Ranching and wheat dominate the agricultural sector.  People rely on horses for work and for play.  Ranch work goes much easier with a good horse and good roping skills.  People favor quarter horses for their intelligence and speed.  So when the kid says rodeo, I ask, “Do you have a good horse?”

Sometimes the face lights up and the grin follows, and I infer, that, indeed the horse is a quality animal. And sometimes the answer comes back, “Pretty good.”

Patient flow slowed to a negligible trickle on Friday; I attended three times more people in the hospital than in the clinic, where I only saw one.

I greatly enjoyed that patient, who gave me permission to write that I diagnosed piriformis syndrome (see my post from 2010), one of my favorite problems because I can fix it before the person leaves.

The insurance credentialing process has cleared me for 4 insurances but not for the majority. I do not understand why, because I had full credentials when I worked here in January.

So I had a slow week, and I would have preferred more patients. All in all, I saw entirely too much drama and irony in for form of patients paying the ultimate piper for their dance with tobacco.

 

Mail the patient in a cardboard box.

The ER doc said with a growl

“Should I cry fish, fair or foul?’

For after the collision

How do I make a decision

About a Boreal Owl?”

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 last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

 

At morning rounds on Monday we gathered to go over the cases from Friday and the weekend. Including the doctors and the representatives from Mental Health, Pharmacy, Nursing, Physical Therapy, and Social Services, I counted 15.

Drama and irony run rampant in those stories, and, as always, drugs and alcohol provided the majority of the good stuff. But the best patient had been brought in after a collision with a car, and still had a pulse, and was eventually identified (with the help of the internet) as a Boreal Owl.  The calls flew back and forth, and the experts agreed that the best course of action included punching holes in a cardboard box and send the owl via mail.  Which is perfectly legal.

I hope HIPAA doesn’t apply to wild animals.

In general I don’t like prescribing controlled substances, and, when I do, I prescribe in small numbers. Though I dislike the benzodiazepines (a family which includes Valium, Xanax, Ativan, Miltown, and Klonipin) the most, I acknowledge they have their uses.  In fact, I would have difficulty caring for inpatient alcohol withdrawal without them.  I find few other uses for them, such as claustrophobia for an MRI or fear of flying, but I in fact found a reason to prescribe 6 pills of one (but I won’t say for what or for whom).

I decided a long time ago that I’m a lousy judge of character. Too many people have fooled me too many times.  So I ask for a urine drug screen on everyone who asks me for a controlled substance, and even a few who don’t.  I find about 50% surprises.

As everywhere, drug seekers come to the facility hoping to get substances with which to get high or to resell. As it turned out today I did a lot of physical exams for people wanting to get into drug or alcohol rehab, and I was able to pick the diagnosis of Health Seeking Behavior.

And today the people wanting to quit tobacco outnumbered the ones who wanted to continue.

February 24th, 2015, a day that will live in infamy

When it comes to the drug they call pot
What is it good for? It’s not.
But they were quick on the draw
To pass a new law
And speed up the memory’s rot.

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. Right now I’m in Nome, Alaska.

Marijuana use runs rampant across the US.

In the early part of the year I asked a patient, a single parent of five and a major pothead, if they would hire a babysitter who got stoned every day, and we agreed that any intoxicant impaired ability to care for children.

My first Monday back brought me to contact with patients running into problems as a direct result of their marijuana abuse.

Mostly hemp excess happens in the context of abuse of other drugs, usually tobacco and alcohol. All three contribute to poor memory, seizures, depression, loss of restful sleep, low testosterone levels (both sexes), low sex drive (both sexes), lowered resistance to infection, poor pain tolerance, social isolation, and irresponsible parenting.

Recently I had a heart-to-heart talk with couples in the maelstrom of dysfunction; the medical problem that brought them in stemmed directly from marijuana abuse. I correctly guessed that both had cold, controlling, distant mothers, and exciting, generous-to-a-fault fathers who failed to follow through on promises and brought repeated disappointments. They readily admitted that each could tell me everything wrong with the other and neither had much of a handle on their own failings. I pointed out that drug abusers can’t exist without enablers, and the cycle can be hard to break because it has roots more than a generation old.

I took a step back and talked about myself. The vast majority of med students, 70%, come from chemically dependent households and most of the rest had other sources of dysfunction in their nurturing families. I skipped the details of my upbringing, but I told them about Alanon and the Adult Children of Alcoholic Parents movement, which use the same 12 steps as Alcoholics Anonymous, and how I went to meetings for 7 years. Every strength is a weakness, every weakness is a strength; it all depends on what you do with them. We agreed that their current approach didn’t work. I replaced a benzodiazapine tranqulizer with Dilantin (most common use=seizure or migraine, but a good second or third choice for almost everything), recommended 12 step meetings for both, and called in Behavioral Health Services.

I learned more about human behavior in dysfunctional families from Alanon than I had from med school.

My last patient requested a back-to-work slip, which I cheerfully supplied. But in the process I uncovered alcohol and marijuana excesses; I accepted at face value the patient’s assertions, and said, “Let me be the first to tell you that nicotine, alcohol, and marijuana will make any medical problem worse and none of them better.”

I could more easily believe that the weed wiped out memory than that all previous docs had missed the chance to educate the patient.

During my two weeks off, the state of Alaska legalized marijuana on February 24th, a date that will live in infamy for those with intact memories, but the pot heads will promptly forget.

I suspect that those in power prefer an apathetic electorate with a poor memory.