Posts Tagged ‘VA’

When is influenza Work Comp?

November 7, 2017

A recurring problem, I fear,

Is the flu I get every year

Am I a jerk

To say I got it at work?

I don’t want to be a pain in the rear.

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. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

Friday I worked but not very hard. I saw more people off the schedule than on due to the number of no shows.  I attended as many people with respiratory problems as with bone-and-joint problems.  As the day wore on I felt, more and more, the aching from yesterday’s 3-hour walk on the ice-covered road leading out of town.  I resolved walk more.

After work Bethany met me in the hospital cafeteria for the weekly prime rib dinner. As Iowa beef snobs we rarely leave home to eat it.  We made an exception; it turned out to be very good, and my piece of meat came large enough to overwhelm.

But my cough, gradually improving over the last 8 weeks, came back stronger than ever on the short walk back to our apartment, and I realized that my tundra-seeing expedition couldn’t account for the ache in my upper back.

I started to shiver, my nose started to run, and my cough worsened. At 9:00 PM I called the Veteran’s Administration for permission to go to the local ER.

I spent 40 of my prepaid phone’s 200 minutes on hold.

My fever and aching worsened, I took Tylenol, I broke into a sweat and I felt better. Which I told the nurse when she answered.

The nurse had no concept of Alaska’s vastness.   She asked if I could get to the VA facility in Palmer, Wasilla, or Anchorage; I told her that I was a good deal closer to the Russian border than  to any of those places.

She knew more nursing than geography.

Eventually she advised fluids, rest, and Tylenol.

Every year I get the flu shot; it’s about 50% effective at preventing flu but it’s 90% effective at preventing death from the flu. And every year, I get the flu.

I got sicker on Saturday evening and went to the ER. I anticipated and got a flu test.

During the wait for results my chills cycled with sweats twice. I took my first oseltamivir (Tamiflu) pill before I left the ER.

But as I had signed in, the slip of paper wanted to know if the problem were work-related.

So many times in the last year I asked sufferers who sought my advice if they wanted the problem put onto Work Comp (or, in Canada, onto the WCB, Workman’s Compensation Board). The vast majority refused; some feared being fired in reprisal, some didn’t want to hassle Human Resources, and some felt their regular insurance would take care of things.

I have almost no social interaction outside the hospital, and I deal with the infected on a daily basis. Until now, I understood the perspective of the self-employed: fear the Work Comp insurance rates will go up.  This time, though, I stood in the shoes of the employed.  And I understood the hesitance.

I didn’t check YES or NO. I wrote, Let’s talk.

Apology and an abnormal thyroid

October 25, 2016

A veteran I might legally be

Does it feel like that?  Not to me

I sure owe a debt

To the Viet Nam vet

Without any PTSD  


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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

I cleared out most of the month to take some holidays, but I accepted a couple of days’ work in a rural clinic not far from home.

I didn’t get formal training on the Electronic Medical Record. It turned out it didn’t take much to get me going.  They let me dictate my notes and they let me work with a nurse who knows her way around.  It doesn’t hurt that I’ve learned 12 new systems in the last 24 months.

I made that observation to a colleague involved in the residency, who noted that our Family Practice residents have to deal with 7 different systems.

The first day I worked in the new venue, I massaged away the headaches of two patients, and helped two others by taking out ear wax. In the evening, I saw three patients in the ER, two of whom required hospitalization and consultation the next day.

The pace of work went well that next day, and I drove home in a reasonable time frame.

Bethany came with me when I returned at the end of last week, driving past corn and soybean fields in the early stages of harvest.

Doctors can take some pretty rough verbal treatment, and an apology first thing in the morning made my day.

I did several pre-op evaluations. In one case, my findings came so markedly unexpected I had to call the surgeon to formulate a plan.

I cared for a Viet Nam combat vet with no Post Traumatic Stress Disorder. I told him how highly I regard the VA.  I see him as a Real Veteran but I don’t see myself that way.  He reassured me that anyone who has to put up with owning a uniform, and having a rank in a system with bad pay and bad management  qualifies as a Real Veteran.  We had a good discussion about emotional resilience and how it plays a big factor in PTSD.  He gave me permission to write about more than I have.

Even if I can’t write about people, I can write about medical conditions. I really like finding abnormal thyroid results.  Because a thyroid gland, either over- or under-active, can cause a lot of different symptoms.  When my thyroid went into overdrive, I could not sleep, I lost weight, I had no inner peace, and I couldn’t sit still.  I know that, sooner or later, my thyroid will quit working and I’ll need to take replacements.  And at the end of the day, the nurse handed me a slip of paper with an abnormal thyroid result, which explained a lot but not all of the patient’s symptoms.




Reverse Snowbirds

October 19, 2016

North we are planning to go

For the experience, not for the dough

If we prefer cold to heat

Can Alaska be beat?

We’ll wait for the dark and the snow.


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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

Yesterday featured a volley of emails and phone calls to Canada.

American liberals love the Canadian medical system; American doctors love to hate the Canadian system. Neither side understands it.  I want to experience it firsthand.  To that end I’ve been working on getting a Canadian license.

Rural areas in both the US and Canada face terrible shortages of medical personnel. Even doctors willing to work in small communities have to overcome enormous hurdles for licensure if they come from out of the country.  In the US, physicians and other skilled workers from other countries bring diversity to the hinterlands.

I wouldn’t bring much diversity to Canada.

After quite a saga, I’ve gotten to the point of talking with a facility in northern British Columbia. They need me, I’d like to work for them, but I have no intention of immigration (though the social fallout from the election could change that).  After I get a formal job offer, the facility needs to file a Labour Market Impaction Application (LMIA) with Immigration.

Yesterday I learned that a realistic time frame for having Immigration review the LMIA and act on it would be six months. I had planned a mid-January start date.

So Bethany and I sat at the table and asked, Where do we want to go?

It took about ten minutes to decide to go back to Alaska, where we have had such wonderful experiences. And, because the window would come smack in the middle of the winter, we decided on the interior, far from the moderating effects of the ocean, where we’ll face cold more intense than Barrow.  Bethany specified she didn’t want to get in a small plane to get there.

I put several items on my original walkabout agenda back in 2010, among them the Veterans’ Administration, because they’ve been so good to me. I let my fingers do the walking through the Internet.

I introduced myself to the clinic manager and asked if she needed any locums. The sunshine in her voice radiated through my cell phone when she said “Yes.”

I specified the agencies I’ve worked with, emailed my CV, and set up a phone interview with the Chief of Staff.

On the phone today I found out that they need me enough to consider working around the lack of authority to make a contract for a locum tenens.

I usually say yes to 6 assignments for every one that actually happens, and I have come to embrace the uncertainty.

No such thing as a free breakfast

November 15, 2015

Uncle Sam sure lied to me
And paid me a much smaller fee
I didn’t know what I’d get
Because I’m a vet.
Still, free breakfast just wasn’t 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, 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, two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.
On Veteran’s Day, Bethany and I went out to a chain restaurant that offered a free breakfast to veterans. I brought my VA card.
Ankylosing spondylitis kept me out of the war in Viet Nam. Later on, when I sought to enter the Indian Health Service, I believed them when they said that I could only get in if I went as a Commissioned Officer (they lied); ankylosing spondylitis would have disqualified me, but a report from a shaky radiologist sealed the deal, saying “no evidence of sacroiliitis.”
The Department of Defense (DoD) controls 5 of our Uniformed Services (Army, Navy, Air Force, Coast Guard, Marines), but not the Public Health Service (PHS) or National Oceanographic and Atmospheric Administration. My service in the PHS qualifies me for Veterans’ benefits at the VA, and the VA has been very good to me.
In fact my IHS service units had Civil Service employees working the same job as Commissioned Officers. They got overtime past 40 hours a week and started with more than twice the base salary. All in all, my naivete cost me more than a quarter million dollars early in my career, but the value of my VA benefit is catching up. And I count my time as a Commissioned Officer as priceless.
There is no such thing as a free breakfast.

Conversations with a Marine and a pessimist; eights shots to the zero

November 11, 2010

Today I went down to the range

Thinking my sights I would change

     In eight shots I was zero’d,

     I’m a vet, not a hero.

With benefits, well, rather strange.

I showed up at the gym an hour later this morning than I usually do and struck up a conversation with the fellow on the stationary bicycle next to mine.

We graduated high school the same year.  He loves watching his career-long project, thirty-two years of work, coming together. He’s looking forward to retiring.  He has a National Guard pension, his wife has a pension as well.  When they get to retirement age they’re planning to work because they love it.

I mentioned that I get VA benefits.  He’d served with the Marines in Viet Nam, and he wanted to know what branch of the service I’d been with.

Most people can name the five uniformed services in the Department of Defense: Army, Navy, Air Force, Marines, and Coast Guard.  Our nation has two other uniformed services: National Oceanographic and Atmospheric Administration (NOAA) and the Public Health Service (PHS).  A uniformed service runs on a military model and has a uniform; I finished my time with a rank of O-6 and I never wore the uniform though it still hangs in my closet.

Contrast as the essence of meaning: though the government calls us both veterans, clearly the word means two different things when applied to us; I never carried a weapon in my five years of service.

I started owning firearms as soon as I could afford them.

Late in the afternoon I took my muzzleloader down to the range to sight it in.   Shot by shot, I poured powder down the barrel, rammed the projectile home, placed a primer under the hammer, and took careful aim.  I adjusted the sights and after eight shots I hit an inch above the bull’s eye at a hundred yards.  When I retrieved the target, all eight shots were in a four inch group, though I’d moved the point of impact two inches left and two inches high.

Projectile weapons enthusiasts in our country tend to be conservative and anti-government.  I showed off my target to another range member.  He asked me if I hunted, and I said I did.  “Yeah, you know, I don’t hunt, but the way this election went, boy, I don’t know, it’s a bunch of crooks in Washington.  You know, you get rid of one bunch of thieves and put another in.  I don’t care what you call ‘em, Democrats or Republicans or Independents, they’re all the same.”

I couldn’t disagree with him.  But I pointed out that survivalists need a botany book more than they need a gun; in the absence of government, hunters will take the animals quickly, but plants will offer a longer-lasting food supply. 

Then I said that even if the government consists of crooks and thieves, we’re better off now than we ever have been; quality and availability of goods, services and information continues to improve yearly.  A depression in 2010 beats the best of times in the ‘50’s.

He couldn’t disagree with me.  As I walked away he thanked me for putting a positive spin on his day.

Five years after a malignancy, I’m back at the blood bank

November 11, 2010

There once was a nurse named Camille,

Who said, “Gosh, how do you feel?

     For you’ve blown your vein.

     It must be a strain.

Can you come back?  It will soon heal.”

During my oldest daughter’s medical education, a medical ethics lecturer said that one should not be doctor to family or friends, no degree of social contact would be appropriate.  But my family’s youngest doctor grew up here and understands how doctors fit into the community.

At my annual physical this morning I talked with a friend and colleague.  Many have said how great I look, how much more relaxed I am; the same words coming from my doctor mean more.  We discussed the turns in his career, and about how we love the day-to-day, hands-on work of medicine. 

My lab work and exam showed no surprises.

When my gallbladder came out five years ago I asked the surgeon to take my appendix, saying, “I don’t want to get up on this table again.”  Ten days late pathology found carcinoid (a low-grade malignancy) in my appendix. 

The diagnosis didn’t change the way I live, but I was banned from giving blood for five years. 

The VA has done marvelous follow-up; all the CT scans have come back normal.  So today, after the appointment, I went to the blood bank.

Consider giving blood, even if you never have; you can justify 600 calories for every unit.

My wife and children donate blood as often as they can (every eight weeks).  I tell adolescent patients complaining about having blood drawn that the people in my family, mostly female, do it recreationally.

I tried to donate two units of red cells, where machinery takes whole blood and returns plasma, but my vein blew early in the procedure and I didn’t have a good vein on the other side. 

Of course I chatted up the nurses and dropped my wife’s and daughters’ names.  They gave me more sympathy than I deserved.

Afterwards I met my youngest daughter at the Japanese restaurant.  I knew more than half the people there as non-physician health care professionals.  I got to talk about my travels and catch up with their news.

One went to college on a rodeo scholarship; the injuries from that time forced early retirement.   The new-found leisure, she said, would go better if a second career would happen; doing nothing does not suffice.

I love the fact that I can’t go out to eat without running into people I know, and I’ve found the anonymity in my travels the most distasteful part.  

This evening a patient called who had a less than optimal experience with a doctor’s visit today.  Remembering that I respect my non-compete agreement, the question became: which specialist would I recommend under some specific circumstances?  The answer came easily. 

My father, an internist/cardiologist/emergency doctor, always maintained a listed phone number.   I have never had an unlisted number, and I doubt my daughter the doctor will.

First Class, Real Veterans, and Me

June 1, 2010

I don’t feel like much of a vet

 Not like some of the people I’ve met

     My maximum risk

     Was a drunk with a fist

But I boarded first on the jet.

Memorial day came clear and clean In Sioux City. With the terminal under construction, detours turned the parking lot ito a maze. National Guardsmen in well washed camo formed a knot of 8 passengers. From the salt and pepper hair and expanded waistline I inferred they were higher-ups and on their way to training. I talked with a young man out of uniform who was also with the guard. Now a police science student, a construction worker, and soon to be a staff sergeant with the Guard; moving his way up the career ladder and on his way to training in Nashville. He couldn’t name the seven uniformed services.

Most people can’t. Most people get as far as Army, Navy, Air Force, Marines, and Coast Guard. A few guess Merchant marine and are wrong. Those who haven’t had personal contact with them don’t know that the National Oceanographic and Atmospheric Administration (NOAA) is a uniformed service, as is the Public Health Service.

I served in the Public Health Service. When I joined up they assigned me a rank and I had to buy a uniform that I never had to wear. It still hangs in my closet. I plan to get rid of it now that I’m sixty. I bought it used, it’s thirty years old and probably outdated.

I would probably volunteer to reactivate if our country had a health crisis involving large numbers of Spanish speakers. Such happened with the Mariel Boatlift, and with an unstable Cuba at our doorstep it could happen again.

The government treats me much better as a vet than they did when on Active Duty, but they treat all the servicemen and women better. Yes, things could be improved but things are much better than they were. Things will never be perfect as long as we continue to send people into harm’s way and combat.

As a country we treat our Service Personnel and our veterans much better than we did.  Some of the warmest, friendliest medical care now comes from the Veterans Administration system.

Coming from Minneapolis to Anchorage the first class passengers and veterans boarded first. The first four times the veterans were called I didn’t go up. I’m not a real veteran, I thought. Firearms were never part of my service to the country. In five years the most dangerous thing that happened to me was being hit in the chest by a drunk in the emergency room. I never really faced anything risky. The real veterans did.

To my surprise the veterans occupied about 20% of the seats.

I decided to be the last veteran on board. With a full plane from the Twin Cities to Anchorage was full I had to take a middle seat. The young man on my right was a veteran, too. He served four years in the Boston area. He never faced danger, either, he says. He was an experimental subject. They put him in a 14000 foot altitude chamber, they exposed him to cold temperatures, and on one occasion they cut a piece of muscle out of his leg.

He was in more danger than I was. I tried to explain the two Uniformed Services not under the Department of Defense, how I had a rank and a uniform. Eligible for veteran’s benefits, I got underpaid and overworked for 5 years.

He doesn’t understand how I don’t feel like a real veteran.

Testosterone deficiency, exit strategies, excellent lunch, saxophone lessons, the VA, and previous careers

February 26, 2010


In any human environment

There is a final  requirement

            Wherever you go

            Whomever you know

You face an eventual retirement


A very long time ago I had a career in radio.  At the time it seemed a long career, now, from the perspective of 23 years at one gig, it seems very brief indeed.  I learned an immense amount about human communication and those lessons have helped ever since. 

I start Thursdays with a brief radio segment.  On the way to the station I drop a friend at Same Day Surgery, then I drive through the darkness and the ice in unforgiving frigid temperatures, the city just starting to wake up.  In the four-minute wind up, Sean, the DJ and I talk about what we’re going to talk about.

I had intended to speak about skin cancer, Sean would prefer to talk about rapid weight loss.

Sean is a real pro.  The control boards bear a superficial resemblance to the analog stuff I used to work with, but there are no turntables or tape decks.  There are computers with digital music, spots, and features.  News and weather are still read live.

On the air, I launch into my spiel about not losing more than a kilo a week if you really want the pounds to leave and not come back.  Sean notes that I’ve been losing weight, I admit I’ve been hitting the gym pretty hard, and he says that he’s been losing six pounds a week.  I finish with my tag line, “Nicotine, caffeine, alcohol, diet, exercise, sleep, and seatbelts.”

It’s the seven word distillation of the good advice I give out through most of my day.  I probably reach more people and do more good in the five minutes a week of my radio spot than in the rest of my work week.

Then into the cold and a sixteen block drive up the street to St. Luke’s.  My OB patient’s anemia reached an equilibrium at Bad but not Critical.  She won’t need transfusion.  I examine the baby, I give advice about iron intake, and I hang on the verge of giving a discharge order when the nurse notes a fever.  We’ll wait another eight hours to see how she does.

I’ll be giving advice on anemia for the rest of the day.

In the doctor’s lounge I eat an orange and I read the funnies, and one of the subspecialists walks in. 

He’s heard about my career move, and we sit and we talk. 

Bad sleep has battered his face, but I don’t say anything.  I have been sleeping poorly for the last fifty years or so and it’s been worse for the last four weeks.  Doctors don’t mention the bad sleep that they see on a colleague’s faces because it’s less interesting than the weather.  It is always there, a feature of the landscape like the sidewalks, taken for granted.  Occasionally I’ll see a doc who slept well the night before and I’ll mention it as a compliment.

We discuss retirement in general.  I say I know I’ve got to slow down, and slowing down is going to be easier and less of a shock to my system when at sixty than at sixty-five.  He tells me he’s stuck in a rut.  Certainly, in terms of his situation and specialty he can’t slow down.  Not on a personal basis and not in terms of the critical place he has in Sioux City medicine.  We agree that slowing down is a good and desirable goal, and we agree that it can be very difficult.

No two doctors have exactly the same job, even in the same specialty or lack of specialty, even if they work side by side in the same office.  Each one has a unique situation.  In our discussions I take care to make statements about my place in the grand scheme of things. 

We also talk about how Ken Tjeerdsma’s death affected the entire medical community.

He was a very good, very warm cardiologist.  He died suddenly in October at the age of 53 and his passing left a palpable void in the Sioux City medical community.  Every doctor in town knew him and enjoyed him and the tragedy made a lot of us reassess our personal direction in life.  I talk about how it played a large factor in my decision.

At the house I start making calls, talking to recruiters, trying to line up work for the coming year.  I leave some voice mails.

At 9:30 I go for my annual VA appointment with Dr. Sly

Dave Sly has been in town for more than fifteen years.  He joined the VA about 8 years ago.  I talk about my career move.  He’s very supportive.  We talk about what is sustainable in a medical career and what isn’t.  He really enjoys his position and doesn’t have plans to change at all.  We agree we have the best job in the world, but we have problems setting limits on it.

Last year he talked about his move to the VA and how he made the pleasant transition to not carrying a beeper.  That conversation left its impression on me. 

I’ve been thinking about exit strategies for years, especially when things don’t go quite right or when things go too long.  We talk about how much we love the work and how medicine can frequently be too much of a good thing.  Dr. Sly has a career that’s sustainable for a very long time. 

Sioux City has sent a large number of really good FP’s into the VA system.  Enthusiastic about their work, they do reasonable hours at a reasonable pace for a reasonable wage with great benefits.

I’ve considered the option, but I think I’ll do my best for society in a spot where I can use my Spanish.

He examines me.  We go over my lab work.

Niacin and fish oil control my cholesterol, my thyroid words well, and my kidney function continues to improve.

My low testosterone explains the hot flashes, sleep disturbance, and the tendency to tendonitis with resistance exercise.  I’m hoping it helps with my cold intolerance.

In the late morning Bethany and I go down to the bicycle shop.

My career in bike repair ran longer than my career in radio, and the two overlapped.  We look over the bikes in the shop, Bethany picks one out, we talk about modifications and we negotiate a price.

The owner of the bike shop looks like he’s enjoying business so much he doesn’t want to retire.

Prices of bicycles in absolute terms have not gone up much but the quality has spiraled upwards. A 21 pound machine would have cost upwards of a thousand dollars back then, today a 20 pound cycle is available for $450.

We lunch across town at the new restaurant, Eldon’s.  We run into friends, and an acquaintance introduces the owner himself, Eldon.

He is much more down to earth and accessible than I thought possible.  He has done well for himself in the food industry with some brilliant patents.  He looks like he’s enjoying himself in this next part in his career.

We lunch on rib eye sandwiches and fingerling potatoes.  The attention to the science of cooking astounds me.

The food is fabulous, the décor is excellent, and the service extraordinary.  The prices are reasonable.  If this place reflects Eldon, I’d like to get to know Eldon better.  And in a town like Sioux City, it’s very possible to do so.

Bethany drops me at my saxophone lesson. 

I had a very short career as a professional musician.  I wasn’t very good at it, and I didn’t retire gracefully.  That was before I thought about medicine.  I still love music and I still love playing the sax, but I hold no illusions about reinventing myself into the industry.

My teacher loves music, teaching, and teaching music too much to stop teaching music, and does a good slow-down business in the private lesson sector.  She has been a friend of the family for years. 

I bring a gift, a jar of home-made peach jam.

It’s good to play the saxophone again.  It’s good to have formal music teaching now. I like learning some of the fine points that I was never taught, because I was self-taught.  I run through scales and I don’t resent them. 

I have neglected my drive for music, and I look forward to nurturing it again.  I don’t care if I lack the talent to get paid for it.