Posts Tagged ‘Veteran’s Administration’

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.

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Executive order puts me between jobs

January 31, 2017

A federal hiring freeze

Has put my plans into a squeeze

It was signed with a smirk

But I just wanted to work,

For the Vets with a cold or a sneeze.

 

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, the fallout of certain Presidential Executive Orders has me cooling my heels at home . Any identifiable patient information has been included with permission.

Usually Washington decisions take months to influence my life, the ship of state does not turn on a dime.   But one of our new President’s Executive Orders, the federal hiring freeze, which garnered the least attention, impacted me the most.

The original plan, to return from Alaska, kick back for a couple of weeks, then return to Alaska to work with the VA, got derailed shortly after the inauguration. Especially because we have a family event in Pittsburgh the last weekend of April, the VA’s requested minimum 90 day commitment has lost its feasibility.

Emails to my planned employer have gone unanswered for a week and a half now, and it’s time for me to move on. Even if I know that winter in Alaska leaves most medical installations short-handed.

Working locum tenens taught me to embrace uncertainty. What happens in reality turns out better than what I had planned.

Back in 2010 I tried to book employment on my own, without an agency. I sent a mailing out to 25 nearby facilities, following up with 25 phone calls and 25 emails.  I got no response.  Since then all my work has been through agencies.  And I would have gone with an agency to the VA but for some shifts in budgets and Federal rules.

A good agency justifies their piece of the pie by value added services; a bad agency has difficulty justifying their existence.

(As a side note, my Canadian venture started with 5 months with an agent who didn’t work out. I struck off on my own, and 18 months later got a job offer.)

In the meantime I’ve been doing Continuing Medical Education with the American Board of Family Medicine, trying to keep me, and them, up to date; I got 56 hours that way. I’ve been doing some Canadian CME, too.  I read the journals that stacked up in our absence.  I go to the gym on alternate days.  I take a nap when I feel like it, several times a day.  I made 4 batches of moose jerky.

I had a novel in need of rewrites on my hard drive; I did 5 edits and submitted it to a publisher.

But I need to go back to work. I miss it.  I have an agent (more accurate than the commonly used term recruiter) looking at spots in Alaska, northeast Nebraska, and southwest Iowa.  Another agency offered a hospitalist spot in New Mexico.

Bethany and I go to movie matinees. We talk a lot about where we might go next.

 

 

Uncertainty usually strikes at least twice

November 2, 2016

Only a second was I left perplexed

And then with the changes I flexed

I know what to do

When the plans all fall through

I ask, What shall we do next?

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. 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.  Just back from a Canada moose hunt, I’ve worked a couple of days in northern Iowa, and I’m taking a few days off.  Any identifiable patient information has been included with permission.

I have been working on practicing in Canada for 20 months. Six weeks ago I thought I was within 2 months, then 3 weeks ago learned that my case would have to go through immigration because I have no plans to immigrate.  And that their review would take 6 months.

OK, I know how to deal with uncertainty. Bethany and I talked for about 10 minutes, with the unspeakable luxury of discussing, Where shall we go next?

If I had the chance to tell me as a teenager what life would look like 50 years in the future, I would not have believed me saying that such freedom could exist in the real world. We decided on interior Alaska for the winter.  And I decided I wanted to work for the Veterans’ Administration, because they have been so very good to me.

I got on the net, I plugged my headphones into my cell, and I started the process. VA facilities run shorthanded chronically, but the one in Fairbanks no longer works with agencies.  And they are willing to work with me directly.

Over the next couple of days I got emails from several people in the institution with a far warmer and friendlier tone than I expected.

Last week I started the credentialing process. I put in a mere 7 hours, finishing yesterday with a trip to FedEx.

Because I cut the agency out, I’ll have to arrange my own housing and vehicle.

Tonight I talked with a man who specializes in selling cars to seasonal Alaska workers and buying them back when the jobs are done. I’ll wait till things have firmed up till I start contacting real estate agents and other housing mavens.

Yesterday I learned that that my putative Canadian gig had found permanent recruits and wouldn’t need me.

Uncertainty, part of the human condition, runs rampant in the locum tenens business, and struck again in less than a week. Yet from experience I know if something falls through, I generally end up having a better time with my second, third or fourth choice than I would have with my first.

I got out my 3×5 cards and started making notes as I cruised Googlemaps and Wikipedia.

I read stuff to Bethany, and we talked. She doesn’t want to go anywhere reachable only by small plane or snow machine, or that has under 1000 people.  I, in turn, define my professional zone of comfort as less than 2 hours from the nearest surgeon.

We have to have indoor exercise facilities for both of us, internet access, and at least one grocery store. Nice options would include a cinema, indoor archery range, and recreational fishing.  I would like to walk to work, and Bethany would like to be able to get work as a teacher.

We’re looking forward to the next adventure.

 

 

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.

Limited Options: in the wake of Obamacare

October 1, 2015

What are they trying to prove?

With this Obamacare groove?

We have limited choice

And limited voice

If worst comes to worst, we can move.

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, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

After lunch I sat in on a round table with a group trying to get out the message on a single payer system.  Our insurance companies currently take between 20% and 25% of our health care dollar and return nothing of value (physicians get 9%).  For every doctor we have two people employed by the insurance industry.  Doing away with the insurance companies would not cure all, but it could go a long way.  A doctor at the table made the comment that we already have a model for a single payer system in this country, TriCare, which gives medical care to Department of Defense, and the Veteran’s Administration.

Yet American doctors love to hate the single-payer Canadian system.

We all voiced frustrations with currently available Electronic Medical Record (EMR) systems.  Updates uniformly brought progressive loss of functionality.  The VA’s system, in use for decades with no updates, continues to function well.

I talked about my experience in New Zealand, a polite society with a very good medical system and a single, nation-wide EMR.  Socialized medicine, but ruled by reason.

Doctors in the US have seen their productivity fall by 25% since Obamacare; we spend increasing amounts of time keyboarding and jumping through regulatory hoops.  We devote more time to documenting the visit than we spend with the patient.  We have few options:  live with the way things are, move, find another line of work, or go to Direct Patient Care (DPC).

DPC means that the patient pays the doctor directly.  In concierge practices, a fixed yearly amount brings the doctor’s promise to limit the panel of patients to a fixed number and provide quick access with unlimited long appointments.

Other DPC docs perform primary care services, take cash only, and give the patient a receipt.  The patient can, if they choose, submit the bill to the insurance company.  Dealing with insurance requires one employee per doctor; elimination of insurance means lower overhead.  More than that, senseless time-sucking regulations can be ignored.

I hear doctors speak seriously about moving.  They would take a cut in pay to spend more time with patients and deal with a more reasonable system, even a single-payer system.

I want to work in Canada to experience it first-hand.  And when I come back, I might work locums for the Department of Defense and/or for the VA.

Job offers and Sisyphus

May 9, 2013

Call brings me no compensation

I struggle with documentation

I might sound like a boor

But our EMR’s poor

And a source of great irritation.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

 I’m starting to get wanderlust again.

Most days bring 6 to 10 job offers, some permanent, most locum tenens (temporary or substitute).  I look at locations and I fantasize.

Places interest me.  A spot in Wyoming evidently has terrible problems recruiting, I’ve received very good offers for the last 10 months.  Indian Health Service has a trouble filling positions as well.  Veterans’ Administration, Armed Forces posts, and Bureau of Prisons chronically seek physicians. 

The one that piqued my interest the most this week was Nome, Alaska, partly because I just finished Michener’s Alaska and partly because I worked in Barrow.  I wouldn’t really take the job because they want Family Practice with Obstetrics, and I swore off delivering babies on May 7, 2010.  Nor do I want to work more than 2 air hours from surgical backup.  Still it looked like a really, really interesting gig.

Ireland keeps sending me information about “hot jobs.” 

I have no interest in cities, not even exotic cities like Albuquerque or San Francisco, though I might consider something in the Denver area because of family and friends there.  For some reason Wisconsin has fallen completely off my radar screen.

I don’t much look for pay rates; still I’m impressed by some of the figures I see.  Bottom lines upwards of $300K come occasionally, but what really catches my attention are the offers of extra money for taking call. 

Bethany and I had such a great time in Alaska in the winter and New Zealand in the fall. 

While I can still remember the absolute euphoria of coming home and seeing familiar faces and sleeping in our own bed, I can feel myself starting to find fault with my current job.  I have begun to dwell on the call for which I receive no compensation and the hours of documentation I do outside of work hours.  The electronic medical record system (EMR), horribly inefficient to start with, irritates me more and more every day.

And if I miss too much sleep I find judgmentalism creeping into my thoughts.  Hospitalizing the same people for the same problems (which come down to bad lifestyle choices) makes me feel like Sisyphus. 

Yet I really enjoy my coworkers, the morale of the clinical staff runs consistently high, and I like doing hospital work.  A lot of docs don’t.  Thus electronic and regular mail recruiting touts “all outpatient” in capitals with several exclamation points at the top of the page.

The clear ability to walk away from a job gives me tremendous negotiating strength.

Unlike Sisyphus, who had been condemned to eternally roll a boulder up a hill, only to have it roll down just before it reached the top.

Three generations of Veterans in one morning

April 10, 2010

 

My experience I didn’t forget

When I talked to the patients I met

            I wasn’t nervous

            When I went into the service

And now I can say I’m a vet.

 

Yesterday I saw four veterans before noon. 

One had been stationed at Pearl Harbor on December 7th 1941.  At 89, the patient maintains a clear mind, erect posture erect, and nimble speech.  The apparent age is a good ten years younger than the calendar age, and we talked about that.  The patient’s oldest sibling just died at age 103.  I told my plans for the future.  From the patient’s perspective, a year away doesn’t seem like such a long time.

A second vet recounted tales of the Mediterranean in 1957.  We talked about what being a short timer feels like.  At tour- of-duty’s end, separation orders in hand, the acronym FYIGMO applied. Until the separation from the service was delayed by a month because the international situation heated up.  We discussed how FYIGMO can go to FUBAR.

I won’t translate the acronyms; in the twenty-first century anyone who can access this blog can use a search engine. 

More than a dozen years ago, because I listened carefully, I was instrumental in tracking down a disease so ridiculously rare that it wasn’t discussed at all in medical school.  There’s only one case in Sioux City and mentioning it would be tantamount to disclosing the identity of the patient.

Mayo Clinic actually nailed down the problem after it had been missed by very good local subspecialists.  The patient didn’t deserve the disease, it’s a disorder of bad luck.  Fifty years ago life expectancy was less than a year.  Now, with very good drugs financed by the VA he’s doing wonderfully. 

The third vet complained about the price of medications.  I asked if he’d investigated the Veteran’s Administration resources.  The answer expressed frustration with the VA system.

The VA had a bad reputation a while ago, I don’t know if it was deserved.  In medical school and residency the joke went:  You walk into a patient room at the VA hospital.  There are three glasses of orange juice on the bedside table.  What’s the diagnosis?

I, like most people just getting used to clinical medicine, guessed diabetes, then sheepishly shrugged my shoulders.

The punch line:  Patient’s been dead for three days.

The VA I’m familiar with is nothing like that.  The Veteran’s Hospital in Sioux Falls remains the warmest hospital I’ve ever experienced.  The employees go past professionalism and into extreme caring.

I feel like poser walking the same hallways with the men and women who faced enemy rifles. 

(There are seven uniformed services: Army, Navy, Air Force, Marines, Coast Guard, National Oceanographic and Atmospheric Administration, and the Public Health Service.  I served in the PHS on a series of Indian reservations.  The most dangerous thing I did was face drunks in the ER.)

My experience with the VA has been uniformly good.  They pay for rheumatology services.  Every injection of the fabulously expensive drug they pay for pries the devil’s fingers from my spine.

Three very good family practitioners in Sioux City left private practice to work for the VA in the last fifteen years. They have expressed intense personal and professional satisfaction with the choice.

I’ve considered it.  The problem remains that two of my unusual talents, my fluency in Spanish and my ability to examine children without force, would not be used.  But as a short-term situation the VA clinics sound attractive.

I’m also thinking about taking a one month position on an Armed Services base.  They’re frequently short-handed.  At the very least, it would be an adventure, and a positive payback.