Posts Tagged ‘Wyoming’

A Canada license takes time.

August 28, 2015

I wait, and I don’t get a call

About Canada and the upcoming fall

I’m a little bit vexed

What shall I do next?

I’m about at the end of my stall.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

Work proceeds on my Canadian license.

Just as each US state has its own medical licensure board, so does each Canadian province.  Just as once licensed in, say, Wyoming, getting licensure in Colorado becomes much easier, similarly a license in British Columbia will make other Canadian licenses less complicated.

My New Zealand license worked for the whole country.  I never even learned all the districts.

But the first Canadian license takes a lot of time.   I started in April.

In New Zealand, compensation came as a package, with no room for negotiation.  The agency got all its funding from the state, and took nothing from either the doc or the client.

My Canadian recruiter receives a finder’s fee from the client, but the doc negotiates directly for compensation, transportation, and housing.

In the US, the recruiter negotiates things like rate, which always includes transportation, car rental, housing, and professional liability insurance.  Those negotiations represent value and labor, and the recruiter gets a chunk of the total package.

Thus less of the total pie in Canada goes to the recruiter and more to the doctor.

The process has gone slowly.  So slowly that I have started to question the viability of an October 6 start date.  Part of the problem stemmed from the 2 weeks’ vacation taken by a key player in the licensing process, another part came from unclear expectations for documentation.

Bethany and I have started talking about where we want to go if Canada falls through, and we came up with Wyoming, Navajoland, Alaska, and Puerto Rico.

We’d like to go back to Wyoming, where we originally met, and, after our experience in Alaska, the idea of the winter doesn’t scare us.

When we arrived in Navajoland I had just finished residency, our first child hadn’t had her first birthday, and we grew together as a couple there.  The Indians taught us a lot about hospitality, and I learned to hunt there.  We’re both curious to see what has happened to the culture in the last 30 years.  And certainly the culture has changed.

I’ve now made seven trips to Alaska.  It’s a very, very big place, and I’ve only scratched the surface.  I’ve not experienced the interior or the Mat-Su valley.

Bethany suggested Puerto Rico because living there would force her to learn Spanish.

And, all in all, we’d rather have a good spot in Wyoming than a bad spot in Puerto Rico.

But the American Academy of Family Practice’s Annual Scientific Assembly starts in a few weeks in Denver, and I know that I’ll be able to talk to dozens of recruiters.


Coding, more complicated than da Vinci

December 2, 2012

I’m not in the overcharge mode

But adequate coin I have stowed

It just seems to me

I shouldn’t need a degree

To figure out the right code.

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.

In residency, I worked for a month in Thermopolis, Wyoming; the title of the rotation was Supervised Rural Practice Elective.  I had my entry into the idea that I might receive money for my work.  My preceptor, a surgeon, charged $15 for an office call, and felt that I should, as well.  Of that amount, $5 would cover overhead, $5 would go to the preceptor, and $5 would end up in my pocket.

Shocked and horrified that I’d make more money than I had intended, I protested that my $1,300 per month salary covered me.

The preceptor wouldn’t hear of it, and insisted I get my share of the proceeds.  In the end, I caved.

I had a great time and met some wonderful people, including a real author, Win Blevins.  I felt funny about taking money for my services.

From that time in 1981 till I left the Indian Health Service in 1987, I didn’t worry about billing—I was on salary.

By 1987, faceless sectors of the government had decided that cognitive medical services could be stratified into six levels, excluding procedures. 

The Omnibus Budget and Reconciliation Act (OBRA) passed in careless haste in 1989, declared six levels excessive, and consolidated things into five, partly in a move to decrease Medicare/Medicaid spending.  But the same act greatly increased the difficulty of deciding the complexity of a medical visit by declaring the existence of a code for every medical service.

(CPT or Current Procedural Terminology codes have to do with what the physician did; ICD codes refer to with diagnoses; the government proposes that in 18 months those codes attain a level of complexity literally 10 times greater than current.  Most docs do not know that ICD stands for International Causes of Death.)

I attended lecture after lecture, trying to understand how to code.  Eventually, the (then) six docs at the Practice Formerly Known As Mine, hired a professional coder.  She tried to start by giving us the essential theory of coding.  We stopped her.  Each of us had been through a minimum of 8 hours of instruction, we said, and none of us understood, and could you please go over some charts with us?

We recouped the price we paid the coder before the sun set; we had undercoded everything up till then.  We brought the same coder back every 6 months to do chart audits.  We continued to undercode but we made improvements.

I left private practice, but even in a salaried position in a Community Health Center, coding has raised its ugly head, now much more complicated than ever before.  The Coding Consultant came on Friday.

She gave a general lecture for an hour, went into some specifics for the practice for an hour, than six of us got one-on-one sessions. 

I started my half-hour with observing that coding has attained layers of complexity resulting in an academic discipline in which one may now earn a 4 year degree, and, at this phase of my career, I wasn’t about to start that course of study.

I still undercode, but not as badly as I once did; I could have billed approximately twice as much for hospital charges as I did for more than 15 years. 

Sure I feel stupid, but those mistakes have passed, and, having learned from them, I move on.

A day off, earthquakes, and the hot springs at Hanmer

May 10, 2011

There wasn’t much fuss we could make,

We didn’t see anything break.

     The large Richter number

     Mattered not to our slumber

We slept right through the earthquake

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  After four weeks in Wellsford, on the North Island of New Zealand, I just arrived at my new assignment.

Bethany and I slept through an earthquake last night.

I’ve felt earthquakes twice.  On a trip back to Wyoming, my hunting buddy stepped on the epicenter of a 4.5 Richter quake; at the time I was in the bathroom and didn’t feel like panicking.

Twenty years ago, during an evening clinic, I stood in an exam room and felt the ground twitch three times.  “Did you feel that?” I asked the patient, who hadn’t felt anything.  Nor had the nurse; my assertions of earthquake met with skepticism till the next morning, when the front page of the Sioux City Journal confirmed the temblor had hit 3.2.

Trip anticipation ruined our sleep on Friday night, and Saturday night the lights of Wellington streamed in under the curtains.  In our new apartment Sunday night, neither of us slept well.

Anticipating no work the next day, we slept deep, sound, and hard till Tuesday morning, awakening refreshed and ready for a day off.  We took our time getting going in the morning; I went for a walk on the border of the property where we’re staying.

We stopped at the Amberley Clinic on our way out of town.  Rex, the senior partner of the group, asked us if the earthquake had awakened us.

Bethany and I looked at each other, and shook our heads.  We’d slept great, we said, and asked if he were kidding.

He wasn’t.  It registered 5.4 on the Richter scale.

New Zealand’s spot on its own tectonic plate and the major fault lines that run through the country brings susceptibility to earthquakes.  Wellington receives hundreds a year, most very small.

Far from over, the aftermath and the aftershocks of the Christchurch disaster permeate the hearts and thoughts of the Kiwis.

I talked to a woman who’d been in the quake.  She described the earth rising up to meet her as she walked, then throwing her to the ground, and then everything moving in waves. 

Many people have quit the city permanently, more families will leave in the future.  The aftershocks ruin sleep, the sleep deprivation piles up, one person decides to leave and the family follows wholesale.

When the ground heaved and rolled, the dirt liquefied and flowed; malodorous muck covered driveways and sidewalks.

But without seismic tendencies, the hot springs an hour from here in Hamner wouldn’t exist.  Bethany and I went there this afternoon. 

I was soaking in the 38 degree Celsius (100.4Fahrenheit)pool and listening to the conversation around me.  One fellow had come because of peripheral neuropathy, one woman had ankylosing spondylitis.

All you need for a support group is two people with the same problem, and while we took the waters we talked about what our disease meant to each of us and how we coped with a relentlessly progressive condition.

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.

I’ve had a great time not getting my first choice.

January 4, 2011

As I look back over the years

At my life and my many careers,

     I missed my first choice,

     Which brings a smile to my voice,

And puts away most of my fears.


Today I got a call from a recruiter who had spoken with me last in October.  He’d gotten close to getting me what looked like a really interesting assignment for the month of December, but it fell through at the last minute.  Thirty-six disappointment-filled hours later another recruiter called me and offered me a job in Keosauqua.

That particular recruiter showed me a level of professionalism I hadn’t experienced in the locums industry.

I took that position in southeast Iowa, and I’m glad I did.  I don’t think people get any friendlier than the folks in Van Buren County, and I don’t think the deer hunting could be any better, even in Alaska. 

I’ve had great experiences not getting my first choice.

Leaving high school I applied to Harvard and Yale, and of course I hoped I’d get into Harvard.  But I had a terrific time at Yale, and I learned a lot about human communication that I wouldn’t have learned at Harvard.

When I lost my job as a disc jockey I decided I wanted something with more stability.

As a medical school applicant my overall picture was so unusual that I was accepted at Michigan State, I got on the waiting list at Harvard, and my state medical school, University of Colorado, didn’t even encourage me to reapply.  Michigan State’s humanistic approach suited me far better than Harvard’s research-oriented curriculum.

I had wanted to do my residency in Greely, but I failed to match there.  Instead I went to Casper, Wyoming, where I met my wife, Bethany.

When Bethany and I decided to leave New Mexico, we listed the Indian Health Service facilities in Santa Fe, Taos, and Durango higher on our list of preferences than the one in Winnebago, Nebraska.  But the other places either filled their vacancies without us or decided they didn’t have vacancies, and we came to Sioux City and settled in.  We kept quoting the movie, Field of Dreams, “Is this paradise?  No, it’s Iowa.”

One year I went deer hunting, and early in the season I found myself ten yards from a doe.  I pulled the trigger seven times and the rifle failed to discharge, till the doe got bored and fed off into the bushes.  I pointed the rifle at the ground and pulled the trigger; it went off just fine.  Later that season I shot the biggest (and, coincidentally, the most delicious) whitetail buck of my career.

When I planned this year of career transition, I had originally wanted to do a palindromic reiteration of the steps that brought me here:  Michigan, Wyoming, New Mexico, and Nebraska.  Step by step, each one of those plans evaporated.  Eventually I found myself on the way to Barrow, Alaska, and if you read my posts from June and July, you can see how happy that turned out.

When a plan falls through now, I take it in stride, and figure that whatever happens instead, I’m going to like it more.

Filling out forms, a disagreeable lifetime pursuit

September 18, 2010

Every day since I left the dorm

I’ve had to fill out the form

     They’re never the same

     Except they ask my name

And how well that I stick to the norm

 In my senior year of high school I got so fed up with filling out forms that I put twenty items on a questionaire, titled it FILL OUT IMMEDIATELY, and left fifty copies at the school’s front desk.  Forty-six forms were filled out.  I don’t like filling out forms, and what goes around comes around.  I think I’m being punished for my prank.  As life goes on, the forms get more frequent and trickier.

I’ve been filling out forms to find new locum tenens jobs.

Even where I am a known quantity with a good reputation, I have to supply the same information.

They all want to know where I’ve worked, where I went to school, where I have licenses, if I have physical or mental problems, if I have alcohol or drug problems, if I’ve ever been convicted of a crime, if I have ever been taken off of Medicare or Medicaid rolls, if I’ve ever been sued, if I’ve ever been refused privileges at a hospital or been disciplined there.

But are the same and the questions are all phrased differently.  “Have you ever been convicted of a misdemeanor or felony in any jurisdiction of the United States or other country?”  is not that same as “Have you ever been convicted of a misdemeanor or felony aside from minor traffic violations?”  I answer the first one with my five parking tickets, my one moving violation, and my conviction of being an illegal pedestrian (I’m not joking).  For the second I can check the No box.

Some ask for the day, month, and year when I started and stopped certain activities, some for the month and year, and some just ask for the year.

They also want copies of my licenses, medical school diploma, and Continuing Medical Education (CME) activities.

I would think that in the twenty-first century checking me electronically would be more reliable than looking at photocopies of paper documents. 

A number of countries would like to import American doctors; one such country’s eighty-seven page query document collection is written so opaquely that even though the official language is nominally English I can’t understand the forms; I’ve been working on them for months and each time I get the jitters.

Today I went down to Staples and got copies made of the certificates which are most asked for: med school diploma, residency certificate, state medical licenses, the details of my legal history, and DEA permit.  I left with five copies of the packet.  I’ll need them. 

I’ve been talking to recruiters for spots in New Zealand, Wyoming, Dubuque, an Indian Reservation and Grand Island.  I’m stoked.

Of course I have to remember that many plans fall through at the last minute.

I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks out I’m having adventures.  To comment on a post, click on the title.