Who has inspired you?

I am a physician in no small part due to the influence of one individual. My Grandmother, LaNere Gilligan, always told me that I would be a great physician, and as we all know, it is very difficult to doubt the truth of our grandmothers. From as early as I can remember, she told me that I would become a physician, and that I would be a good physician. I never doubted what she said, and really never wavered from this idea, this goal.

She came from a much more practical time in the world. She was born in 1916 , Woodrow Wilson had been nominated during the Democratic National Convention, and WWI was raging in Europe, the United States was not to enter until one year later. She was the youngest of five, a child of the depression, for whom her parents died when she was young. She grew up in Austin Texas being raised by her eldest sister. She met my grandfather in Junior High and dated him through college. They were married in 1939. She studied nursing a Seaton School of Nursing in Austin Texas, and practiced as a nurse for many years. Many things influenced her life, and subsequently mine, but her time during the depression and her life as nurse were the things I remember the most.

From the Depression, she gained a sense of frugality. She always planned for the worst, expecting that things could decline as they had done when she was young. This frugality was something that my Grandfather had never known, he was the son of a drag-line operator, and his father always had work in the coal region of Indiana. LaNere, knew hunger, and knew early that she was an extra mouth to feed, one that was not yet able to pay her own way. This drove her toward self-sufficiency, and in that time this meant secretarial work or nursing.

Nursing was very different in the 1930’s, as was medicine. It was a time when great discoveries still lay ahead, penicillin had only come to light in 1928, and the use of certain advance surgical techniques (electrocautery) were just beginning in surgery. It was a time a paternalistic medicine. She learned her craft during this time and it influenced her interactions with physicians from that point forward. She was of an age that did not question the physician, right or wrong that was the time. She learned many skills from this environment, one of which was to encourage behavior she wanted indirectly, and this she used to great effect on me, in my youth, as she molded me into a physician.

This influence came in many forms, from the first anatomy book at an early age (pop-up), to a Gray’s Anatomy for Christmas. She encouraged exploration and investigation in all things, there was never a wrong answer, just a conclusion that needed more work. As well, there was the need to ensure the well rounded nature of her young pupil, indeed of the young physician. Lessons hard learned from an earlier time had to be passed on, and an appreciation for the lives of others must be instilled. These she did without my even knowing or seeing. Understanding of our shared past, from whence we came (the family history as it were) should be learned so that you would be grounded for the future.

As with all things, the time comes when those who influence our lives pass on from our view. Their care and concerns, the lessons learned are instilled deeply in our lives, so much so that they live on within our hearts and minds. The influences they have laid upon us are so subtle and so deep that we can hardly see where they end and we ourselves begin, they simply are part of who we have become. These influences carry us forward and help make us who we are. So, on this day, as I reflect on the life on LaNere Gilligan, one of the most influential people in my life, I send my thanks to her for all that she taught me, for the unending support and for the steadfast belief in what I could become even when I doubted myself. May I always act in a manner befitting this legacy, as may we all.

LaNere Gilligan (Thornberry) June 5, 1916-November 27, 2010

Reflections on practice

It has been a while since I attended an international conference. In fact, I have not really been to any formal national or international conferences since I moved from Texas to PEI. I am spending today and the next several days in Vancouver, British Columbia at the Society of Teachers of Family Medicine, STFM. Today the preconference workshop on Palliative Care promoted a reflective sense, and allowed the opportunity to look back at how much has changed during the last two years.

The pre-conference workshop was geared toward developing a curriculum for the education of residents and students in palliative care. It may have been the group, the topic, or the electromagnetic forces at play, but the room was full of many people who love what they do, strive to be the best at their profession, and are keenly aware of their short comings in their endeavor. It was interesting to sit in a room full of people who are mindful. The listening and discussion had a different tone in this room, it reflected the struggle. Into this room, at the close of the day, we turned our attention to ‘self care’.

In the realm of palliative care it is a fact that burnout shadows the work, and in the crucible of academic medicine, the shadows may overtake you before you are aware. In an effort to assess our needs as a group, a small exercise was in order, a pictogram representing where our time and efforts are spent. After drawing a box and labeling the corners (work, family, friends, self-care) the time was divided to reflect the amount of time and energy we spent in each corner. The comparison of my time slices today look very different from the slices two years ago.
Then
Work 70 hours (71%) Family 14 hours (14%)
Friends 7 hours (7%) Self care 7 hours (7%)

Now
Work 50 hours (58%) Family 21 hours (36%)
Friends 7 hours (8%) Self care 7 hours (8%)

The feeling surrounding life has changed far more than the 13% reduction in my work hours reflect. The chaos that comprised a fair bit of life is no longer present. The sense of having to run to keep up is virtually absent, and the smoldering resentment surrounding work has vanished. This change has allowed for a more important evolution in patient care, it has allowed for the return of empathy.

Mindful patient care is something that is difficult to achieve if you have sliced your time so thin as to become transparent. If there is no substance to you, no opportunity to focus your attention on the patient at hand, then you are unable to be mindful and present in the room with the patient. It is this presence that is transformative. Being present, attentive, and without distraction allows you to see the patient as they are, at that moment, in the moment. In seeing the patient, the moment for change occurs. The ability to look past the superficial mask which we all wear allows you the chance to speak to that divine spark within each of us, that little bit of God we all hold, the portion of each patient that can effect change. It is seeing this person, hearing this person, and speaking to this person that we act in ways that allow them to see the change, to become the change.

It is in the quiet times that we can look and see the things that need to be done, and move the things that need moving. On the Island, in my practice, with my patients, I am privileged to observe the comings and goings of these quiet times in the patients and families for whom I care.

Namaste

Do the right thing.......

There has been a profound change in my practice since I left Texas, hospice and palliative care have become a very significant portion of my practice. This change has left me with deep questions regarding the practice of medicine, and has left me considering the obligation to ‘Do the right thing’.

When the focus of your practice is to diagnose and treat with an eye toward recovery, the right thing is a bit more obvious. Your charge is to figure out what is ailing the patient and make it right as quickly as you can with the least amount of harm to the patient. It is a balancing act between beneficence and harm. Harm comes in many forms, cost (for unnecessary tests), radiation (CT scans), pain (invasive tests), misdiagnosis (finding the wrong thing, or finding something incidentally that leads you on a goose chase), and side effects (every treatment has a risk). You are always balancing this against the good you are working to accomplish, asking yourself if these things are really needed in order to help the patient heal.

How does this change when your role is to help someone have a ‘good death’? The purpose is no longer recovery, but to comfort, and that changes the equation. Comfort care seems very straight forward when presented as such. You provide care to the patient that brings them comfort, relieves their suffering, and makes them at ease. At first glance this does not appear to be that difficult, and in many cases it is not. The symptoms that the patients have are such that they can be managed without any direct risk to their well being and care is provided with a minimum of risk.

When pain is a significant symptom, then the situation changes, the risks increase and the chance of harm is ever present. Most patients fear the suffering associated with pain. Pain is a great teacher; it is there to keep us alive. Pain is there to make us release the hot object, struggle against the trap, fight against the darkness. Pain is an intrinsic element of humanity, it is the great equalizer. The treatment of pain is a first order priority in the care of the hospice patient. In the minds of many, the control of pain is essential to a ‘good death’. The unfortunate risk involved in the treatment of pain is the hastening of death. The medications that are used to treat pain, narcotics primarily, all have side effects that include depression of the respiratory system, that is, they slow your breathing, sometimes fatally. The inclusion of anti-anxiety medications often makes the respiratory problem worse, and unfortunately many people have a great deal of anxiety as they approach death.

How do you balance this equation, providing for the comfort and care, but avoiding the ultimate harm? It is easier when the patient looks you in the eye and tells you what to do “I do not want to suffer, and I do not care if the medicine makes me die sooner”. But what of the patient who asks you to “Do what you think is best”. What is best? How can you know? What is best for this patient? Do you work to relieve the suffering knowing you are shortening their life? If that time is but a few hours you might not worry, but what if it is a few days, a few weeks? What if the treatment you provide gives complications that increase the suffering of the family? How do you balance these equations?

Currently the province of Quebec is having a vigorous debate on euthanasia ( CBC, Forum, Government). This debate is also happening in Europe on a larger scale (BBC , Research Article) and in the United States as well (Grid on Legal Efforts by state, Annals of Internal Medicine ). I suspect this debate will continue throughout my lifetime as it has throughout the lives of others. However, my question for now remeains, when does the provision of care and relief of suffering cross that line, and how will I know if I am doing the right thing?

On not knowing everything………

We make decisions every day, most of them without any consequence at all. What are you having for lunch? Going for vacation? Getting your friend for Christmas? These decisions may take a lot of our time, but the outcomes do not usually make a large difference in our lives. What happens when the decision has greater implications? What happens when your decisions may impact the health and welfare of others? How comfortable are you with the unknown? When you clearly do not know something does it make you uncomfortable? Does it make a difference if this is public or private ignorance?

In medicine we often have a chance to review these thoughts as we go in to the ‘office’. As a family physician, often you are seeing the undifferentiated, the patient who has not been seen before for the problem at hand. These patients could have anything, and often do. This is the heart and soul of family medicine, and more than anything else, it is this aspect of the profession that I often find the most difficult in the long hours of the night.

When students ask me what they should do for a living, I often ask them how much tolerance they have for the ‘gray zone’ of family medicine. By the time that they have spent six weeks with me in the hospital and clinic, I usually have a good feeling for their tolerance of the uncertainty that caresses every action of your day. Those with minimal tolerance are encouraged to pursue specialties where, to quote one of my local dermatologists, you can ‘know more and more about less and less’. This whittling of the number of problems that you are responsible for allows you to focus in on a subset of problems and become expert in these diseases. You learn to recognize the intricate variability of a presentation of each of those diseases, learning the common and uncommon presentation of ‘your special illnesses’. When a patient arrives in your office with a consultation, your role it to determine if this patient represents one of these diseases or not, provide advice on the management of the disease if it is in your realm, and if the patient does not have anything in your specialty identify what they do not have and return them to the referring physician. As a family physician, these patients are often back into you office with a long list of what they do not have and you are back to square 1.2 where you restart your diagnostic processes again, the gray zone of uncertainty has returned.

Students who truly relish the gray zone, exhibit significant comfort in the zone, and are willing to work hard to develop tools to improve their work in this zone become the rural physicians of old. These folks work on ‘gut’ instincts at times taking a chance on a hunch when the data is not always there, but the feeling that you have is undeniable. This is a skill that some are born with, but most develop over time as a side effect of lessons learned. These lessons come through every patient that passes through our clinic, every specialist report that lands on the desk, every specialized test that you have ordered. What is important is how you supplement this instinct, and that is something that has changed over the last years.

In 1996 I worked in a small rural clinic at Dugway Proving Ground in the west desert of Utah. I had received the minimum training needed to not be outright dangerous to people, but I had hardly received what would be called sufficient training. In this location I performed the duties of a rural family physician, taking care of any and all that came through my doors. In my examination room I kept a copy of the Merck Manual so that I had the best compact source of information to assist me with the diagnosis and treatment of my patients. It served to help me fill in the large gaps in my knowledge base as I saw my patients, and I often took it off the shelf while the patient was sitting on the table. I knew what my limitations were, and had no difficulties letting the patients know that my fund of knowledge had definite limitations. This was one of the driving forces behind my desire to expand my knowledge base, complete my training, and my enthusiasm for on-line evidence based medicine.

In order to work well in a rural clinic and do so without waiting years to develop the fund of knowledge that comes from practice, you must have a series of tools at your disposal to help you shrink this zone of uncertainty. For my part, DynaMed, PubMed, and ePocrates serve as my peripheral brain. They help fill in the gaps in my knowledge base, remind me of things I once knew, and help me to become a better physician. Despite these tools, there are still times when you find yourself faced with patients for whom you simply run out of good ideas. These patients are the ones who haunt you as you sleep.

As a family physician, even the presence of these tools may leave you with a patient for whom you still do not have an answer. These are the patients that drive you to study more, to deepen you fund of knowledge. These are the patients that leave you with a feeling of inadequacy as you pull on your hair at night trying to figure out what may ultimately be unknowable. In a rural setting, this absence of knowing can eat at you as you see the patient routinely and feel you inadequacy tugging at your sense of self. What is left is often something very different than you might want something somber and reflective as you look back on the day a thoughtful player in this world.

The beautiful flame fractal on this page came from the following website

http://lojjic.net/gallery/1000words/20031208-flame-fractal.jpg

A lot happens in a year……

Despite the truth the calendar flaunts, the fact that a year has elapsed since our arrival in Canada is surreal. In fact, it was only when I was answering a question about how long I have been on the island that the realization of times passage hit home.

“One year, as of today”

Granted, a few days has passed since that statement brought me to a stop in my tracks, but the time has allowed for reflection of the year passed and with that reflection comes today’s post.

Nancy asked me what I had learned in the last year. The easy answer was the use of standardized units for lab values (different from the US system), as well as the odd names for all those drugs that I spent time learning, plus a whole bevy of new ones that are not approved in the United States. However, that answer would not really get to the truth of the last year and while placating some, would not be satisfying.


Universal health care is good for people. I have come to more firmly believe in this over the past year. It is not perfect by any stretch, and I am sure there are other places that do this better than Canada, but the Canadian model of care, providing some baseline level of care for everyone is better than the system I came from. The Canadians value the community, and therefore they value coverage for everyone, even if it means that you pay more to cover someone else. They accept this fact and feel that the end result is worth the price. The end result is that people can be seen and treated before things get very bad. Now, the downside is that not everyone has a Family Physician or NP looking after them because there are doctor and nurse shortages here as there are everywhere else. However, you can be seen without worrying that it will break the bank, and you know that if you get sick, the cost of your recovery will not leave you in poverty before you are ever well. Things do not move at the speed of light, but that also means that the doctor or NP has to think twice about ordering some expensive test with a waiting list. Not everyone who has a migraine headache gets an MRI to rule out a cancer.

Practicing medicine is fun. With the removal of the bountiful paperwork that seemed to reproduce on my desktop in Texas, I have re-discovered that I enjoy practicing medicine and taking care of patients and their families. It is the same joyous feeling I had when I practiced in Dugway Utah, that feeling of connecting with and helping out patients every day I went to work. I do not feel like an overpriced administrator, and I certainly do not feel that I am being given paperwork as a way to discourage ordering a test/study. I get to sit down and talk with my patients, listen to their stories, and take care of their needs. The fact that my panel is stable means that I am seeing the same people over time, therefore, once I get them caught up on their prevention, I have additional free time to chat about other important things like their kids and grandkids, the state of their farm, the lobster catch, and of course commodity prices. This provides a great deal of insight into the inner working of the island world, and with that comes a deeper understanding of the inherent worries of the lives of the islanders. This knowledge allows me to understand them in ways I was never able in my previous practice. It has brought the joy back to my practice and that is invaluable beyond measure.

Life outside of medicine is important. The change in pace over the last year has been the most surprising thing on this journey. When we arrived last year we did not understand how people could spend all their time ‘Up West’ and rarely venture to Summerside or Charlottetown. The idea that you had everything that you needed ‘Up West’ seemed ludicrous when we arrived, after all, how anyplace could ever have ‘everything you needed’. The interesting thing about needs and wants is that once you have taken away the drumbeat of advertising, slowed down enough that you notice the change of the seasons, the number of things that require travel to obtain reduces on its own like a neglected garden. It is the deceleration of time which allows you to look beyond the demands of tomorrow to see the glories of today. As time slows, you can see the world, listen to the wind, and connect with the earth in a way that cannot be rushed. This modifies you sense of need, and provides a deep sense of fulfillment in your routine life that no longer has room for the unnecessary. You begin to live each day with joy and purpose, that is, you begin to look at your day differently. You ask yourself if the things you are doing are really worth spending one of your precious days upon the task, or if the time would not be better spent on something more important. These changes percolate into the way you work so that you begin to ask the same questions of the tedium that intrudes upon you day. Your realization of what is and is not important allows you to put medicine into a place in your life, no longer the shadow over your life.

The year has taught us many things, has slowed us down enough to look beyond the ordinary to see it for what it truly is, wondrous beyond the imagination. So much in such a short time, makes you wonder what we will discover next!

Healthcare difference part II……….Rationing in the US

Anticipating the differences between the US and Canada, I focused on the rationing of healthcare. When most folks I know talk about the difference between the delivery of health care in the two nations, rationing and quality are two differences that stand tall among the potential pitfalls of a nationalized system. Rationing occurs in both systems, the prime difference is the transparency with which it occurs in each system.

Rationing in the United States
Many people are surprised to learn that rationing of healthcare resources does in fact take place within the United States, and the absence of transparency is why most American do not recognize the rationing. The rationing of healthcare in the US occurs in two forms- insured and uninsured.

Uninsured
If you are unfortunate and lack health care insurance in the United States, then by definition you ration the health care that you receive from the system. You ration your healthcare because you have no choice, it is simply too expensive to be sick, and even more expensive to purchase insurance. So like most folks when money is short, you do without things that seem to be luxuries. This means that you do not enter the healthcare complex until you have no choice, and enter the system when your health has deteriorated to such an extent that you must enter the system because you are simply too ill to do otherwise. This illness may be something seemingly innocuous such as a bad case of the flu, or something more complicated. In the end, it means a trip to the emergency room/urgent care/walk in clinic for the help. Often the choice of where to enter the system is dictated by the available cash on hand, with those who have the fewest resources shunting to the emergency department for their care. Unfortunately this means that they are entering the system at the most expensive point.

This makes little sense economically but it is one of the only ways people can be guaranteed that they will be seen and treated, and it is the Emergency Medical and Active Labor Act that makes this possible. This obliges the emergency department to make sure that the patient does not have any life threatening illnesses and that they are medically stable before sending them home. This does not mean that everyone has to be treated, but in a practical sense, everyone is. The line between diagnosis and stabilization to treatment is very small, so it makes little sense not to just finish the work. This is in part why so many people arrive for prolonged waits in the emergency departments across the US. Patients who have more discretionary spending often go to the Urgent Care or Walk In clinics to be seen for their minor ailments. These clinics are far more efficient than the Emergency Departments, but payment is expected at the time of service. In both cases, the treating provider has no obligation to care for the patient beyond their encounter, that is, they have no obligation to look after the long term chronic health care needs of the patients they treat. In essence they are rationing the care they deliver; they do not deliver the long term care.
If you need hospitalization and you lack health insurance, then this prospect is a nightmare. The EMTALA obligates the hospital to admit you to the hospital, stabilize you condition, and then look toward discharge. Hospital costs are such that even an overnight stay in the hospital may cost you over $1500 which for a family of four with two working parents earning $50,000 a year will find difficult. Additionally most folks without insurance work in jobs where there is little if any paid sick time, so there is the burden of lost income for the period of time you are hospitalized as well as any time spent recovering after you leave the hospital. In fact recent studies (prior to the economic slump) indicate that health care expenses contribute to bankruptcy in 50% of the cases and when looking at housing problems (failure to pay rent or mortgage payment), 25% are due to healthcare expenses.

The Insured
If you are one of those fortunate enough to have insurance, you are still subjected to health care rationing, but unlike the uninsured, it is often a more complex form of rationing that takes place. It is not called rationing in the usual sense; it is couched in terms such as “covered services”, “preferred provider”, “pre-existing condition”, and “denied claims”. Here is how it plays out from the perspective of a physician inside a very organized integrated health care network.

When a patient presented to be seen in the clinic everything went very well as long as I did not ask the system do more than it was prepared to accomplish. In other words, if I saw the patient, diagnosed the condition, and treated it then there was no particular problem. However, if I wanted to involve other providers, provide more than one type of service on the same day, or provide care that was outside of the usual scope the rationing began. As an example, if I a patient can to me with a mole on their skin that was concerning and I determined that the mole should come off, then proceeded to remove this mole during the same visit, it was often not paid. What this meant to the patient was inconvenience, in that I would diagnose them and have them come back on another day for the procedure that should have taken place at the same time as the initial visit. If I wanted more specific testing it often required additional paperwork to be completed in order to justify the service. Often this would involve a phone call to someone who would approve the service. These same steps were required when medications outside of the formulary were required, or when a referral to a specialist was indicated. These additional steps increased the time line for a patient to obtain the services, and each step provided an opportunity for the insurance company to decline the coverage. Often after a claim had been submitted, additional paperwork would come through that would essentially be asking if the condition being covered might have been a pre-existing condition. If you are unfortunate enough to be found to have received services for a pre-existing condition, then the claims will be denied and you will be stuck with the bill for any services that can be related to that condition, after the fact.

An additional component to the rationing of health care for the insured patient is the conditions and services covered as well as the amount of coverage for these conditions. The fact that you have insurance is not a guarantee that you will receive treatment. If you need treatment for a condition that is not covered by your plan then you are out of luck. Likewise, the type of treatment that you may be eligible to receive will depend on the terms of you plan. These terms may change without your notice, and you may be left holding the bag. Finally, if the cost of your care exceeds the threshold of the plan, then you insurance runs out and ceases to pay for any additional costs. This is in fact rationing. If you have insurance and you do not need much then you get what you want without any real trouble. If you have significant needs, then it is likely that the insurance company will ration your access until you run out of coverage or they find a link to a pre-existing condition that allows them to decline payment for the claims. If you are uninsured you really only get acute treatment and nothing more, at great cost.

In the case of the US, the rationing that occurs is done in a manner that is not transparent and is without any recourse. You cannot vote out the people who have rationed your healthcare, you cannot sue the insurance company that has decline your care, and the majority of people cannot afford to get sick. In a system where healthcare is nationalized transparency is a key element to the rationing of care…..more to come.

Comparison Shopping for your Health Care System Part 1

In the end you are still taking care of the patient

Since I have been in practice in Canada for six months I thought it might be time to reflect on the similarities and the difference s between the US and Canadian system of health care. As a reminder, I am a Family Physician. This means that I take care of whomever walks through my office door to the best of my abilities regardless of age, sex, or ability to pay. I see everything, and refer to specialists when I am out of my comfort zone, or have run out of good ideas. So a good place to begin our review would be in the typical clinic day.

The View From Texas

When I practiced in Killeen for Scott and White my day started in clinic around 8:30. I would see a patient basically every 15 minutes until 12pm, break for lunch, and start at 1pm and continue until 3:45pm. This resulted in seeing about 26 patients a day give or take (depending on how many physicals I had that day).

I usually arrived earlier in the morning to try and answer all the patient messages, look over lab results, complete forms, and answer e-mail prior to the first patient of the day. I dictated my charts as I went and that usually took 2-3 minutes per patient so I spent roughly 10-12 minutes of each visit with the patients. During that time you would try to complete all the work that needed to be done for this patient. The presence of the electronic medical record allowed me to review all the visits since the last time I had seen them as well as all the specialty visits. It also let me look and see if they were up to date on their labs, preventative care, and such. Some days the computers worked well and this did not take much time, other days they were slow and it became difficult. In general, my patients were older with my average patient being late 60s early 70s with the occasional child thrown in for variety. If a patient needed a procedure done often it happened during their visits, or was quickly scheduled for my dedicated procedure day.

The days felt very busy and I usually returned home feeling fairly worn down. I usually left the clinic in Killeen after 4:30 or 5 pm and then headed to the house. As part of my practice in Texas I did the occasional delivery usually in the wee hours of the night, and one week of every six was spent working in the hospital taking care of the hospital service. On the whole, the patients that I took care of in clinic and in the hospital were older sicker folks.

The View From Prince Edward Island

My practice in Canada is usually starts around 7 am with hospital rounds at the Alberton hospital where I see my one or two patients, then I drive to O’Leary for hospital rounds on my one or two patients. I arrive at the clinic between 8:30 and 9 am to begin my clinic day. I see a patient every 15 minutes from 9 am through 11:45 and then from 1 pm until 3:45 pm give or take I see between 23 and 25 patients a day depending on the number of work-in patients.

During the visit you work on many of the same issues as I did in Texas, catching up on preventative health care, reviewing labs and such to monitor chronic illnesses, and cajoling patients into changing their lifestyles. Since the notes are handwritten, there is no time spent dictating the chart (and thus no time spent signing off on dictation). Since it is a paper chart, there is a bit of work to keep the flow-sheet organized so that you do not have to dig through the chart each time you want to review preventative care. Because of the manner in which the clinic is arranged, it is difficult to perform procedures in the clinic, so I often send those to myself when I am going to be working the urgent care clinic. You still have the usual lab to sign off on, as well as the consults to review and such, but the paperwork that seemed to be such a large part of my practice in Killeen is not here. I do not have any pre-approval insurance forms to complete, and I cannot think of the last time that I had to complete a Pharmacy Assistant form for anyone. The patients do not seem as ill either. I have some terribly sick patients (i.e. the renal failure alcoholics with diabetes) but they are not as big a part of my practice as they were in Texas. The pharmacy does not fax forms to me for refills, they either refill the medications for one month and have the patient make an appointment to be seen, or they call me directly during the day and I give them the go ahead. This relieves all the pharmacy paperwork that I had from Texas and it was a huge chunk of my paperwork.

There are some distinct differences in the prevalence of certain medical conditions, specifically thyroid disorder, crohn’s disease, celiac disease, and cancer, but I think that these represent the effect of a small isolated population (after all there was no direct connection to the mainland until 20 years ago). I usually complete all my work by 4:30 or 5 pm and head home. I am no longer delivering babies so I do not have those night-time calls. There are two duties that I did not have in Texas that are part of my practice, the Urgent Care Clinic and the Emergency Room. On average I have one call in each location weekly. Usually they are back to back where I work the UCC one day and the ER the next. The hours for the UCC are from 8 am to 8 pm and the volume is variable. The ER is a 24 hour shift, and volume is steady but manageable. As influenza has arrived in our part of the island, the UCC and ER have become very busy places. Despite the addition of daily hospital work and the shifts in the ER and UCC I do not feel as tired as I did when I was in Texas.

Quelle est la différence?
The question in my mind is why am I less fatigued than when I was in Texas. I have been giving this a great deal of thought over the last weeks and I have come to a couple of conclusions.

First, the ever present push in Texas to see more folks all the time felt like a weight on you back. The addition of 3 patients a day meant an additional 15 people a week really seemed to increase the work load (especially when you translate that into the additional dictations, labs, and pharmacy faxes).. Where I feel like I have the time to talk to folks here, I never really felt that previously.

Second, the patients have a different level of expectation in Canada. In the US I always had the feeling that patients wanted everything done all the time whether they needed it or not. I felt like I was always counseling patients about why they did not need antibiotics, an MRI, or a CT scan. The sense of entitlement that I felt form the patients in the US was always present as was a continuing concern that someone was going to file suit for the care that you provided. I am not saying these are rational feelings, but they reflect the feelings of the day when I was practicing. As well, my conversations with my colleagues during lunch confirmed that others felt the same way. The patients here do not demand that everything be done, and if you are sending them for extra tests, they do not fret if these tests take a couple of weeks to get accomplished. With the malpractice laws in Canada, the frequency of litigation is low, and patients do not seem to view it as a lottery like chance for a big win.

Finally, paperwork here is not nearly as onerous as it was back in the Texas. I know it goes against what I initially expected from a government run system, but the amount of paperwork that flows through the clinic is not nearly as copious. This burden was one I did not really appreciate until it went away, and I do not miss it one bit.

Well that is the first view of the similarities and differences. I will post more on this subject over the course of February and try to continue to fill in the gaps so you get a good feel for what is working and not working in both systems. Stay tuned.

Merry Christmas From PEI

It’s Christmas Eve, Irving Berlin’s White Christmas is on the TV, snow is gently falling outside (making our own white Christmas), the furnace is piled high with logs, and I am putting the finishing touches on our yearly Christmas greeting. Our Christmas greetings come to you this year from the North Atlantic Island of lobster, potatoes, and ADL. ADL? ADL is the maker of the BEST milk, chocolate milk, butter, and cheese you can possibly imagine. Drinking a glass of their chocolate milk is like drinking a little slice of heaven (I just finished a glass!). Well, our greeting comes to you, as you know, from 83 Lewis Road, Union R.R. 1, Alberton, West Prince, Prince Edward Island, Canada.

We left the U.S. in August, leaving the dog days of summer in Central Texas (the day we left was 107 degrees with 100% humidity), and headed across the U.S. moving up the east coast. So, here we were, Gil and I, accompanied by 2 dogs, 1 cat, and 1 Lucy Bird, pulling our horse trailer filled with things we thought we would need until our household goods arrived, headed for Canada. Gil and I had never driven through the states lining the east coast so we were really looking forward to seeing the land. An added bonus, especially when traveling through the southern states, being in the land of really really good grits! Yummmm. The only part of the trip that truly sucked was going through Atlanta with a horse trailer, and we didn’t even go through at a rush hour time. Thank God Alli and Jesse gave us the wonderful gift of a GPS before leaving or the suck factor of Atlanta would have been significantly worse!

We stayed for a few days with Alli and Jesse in Swanzey, New Hampshire and the rest was greatly welcomed by us and the animals. We had a wonderful time with Alli and Jesse and got to spend some time watching Aaron, their 7 m/o son, being Aaron. He is a truly happy and delightful child. Even though this is their first and they have little parenting experience (7 months to be exact!), I told them they HAVE to be doing it right or he wouldn’t be so happy and well adjusted to life. He is a joy to be around. We had such a wonderful time seeing Keene (Swanzey is just a couple of blocks from there) and Walpole (where their family business is located). We brought sausage from Green’s Sausage House in Zabzkville with us and Gil made a huge pot of his gumbo. We had our usual trio of gumbo, baguette, and wine, accompanied by lots of wonderful conversation.

We crossed into Canada at the border crossing located in Houlton, Maine. We were prepared with a file box full of papers which were required to get us, the animals, and the car across the border and fully expected to spend hours going through papers and getting it all sorted. We were shocked and pleased that it was so quick and painless. Gil got his work visa and I got my Canadian papers and we were across the border in less than an hour (none of the documents we worked so long and hard to get in the U.S were asked for!). As we drove through New Brunswick headed to PEI, we looked at the scenery passing us in a different way than we looked at Canada all the times we had visited. This was our HOME now, and it makes you look at your surroundings quite differently.

The horses made it here about a week after we got here. There was a bit of difficulty getting them across the border. The transporter called me in a panic at midnight saying they weren’t going to let them across. We finally got everything worked out so the border agents understood why we were bringing them here and finally in the wee hours of the morning they made it across into Canada. When they made it to me they had a bit of a deer in the headlights look, but that is to be expected. They were on a transport from Texas to Maine for 3 full days without stopping, stayed over in Maine for 2 days, and then were on another transport for another 12 hours here.

Cowboy and Olivia have settled in and done well. I have been riding Cowboy and although it took him a bit of time to settle in and get back to where we were in Texas, he has been just awesome. In the past, when he traveled, a show was at the end, so he was in full (and I mean full with bigness and glory!) saddle seat mode. We finally got the dressage brain engaged again and he has been spectacular. I have been lunging and long lining Olivia since arriving, but haven’t ridden her yet. She has continued to be sound as can be and I have looked long and hard to find a driving trainer that I could continue lessons with and perhaps start Olivia driving. We attempted it once before with my trainer, Tom O’Carroll, in Texas, but she didn’t stay sound for it. Since then, we have had her on Naproxen, and she has stayed sound. The bad news is I can’t find a trainer. Most people on the island harness race which is, of course, not the same at all. I have, however, made a couple of friends who drive (not competitively) – carriage in the summer and sleigh in winter. So, I am going to get a bit of sleigh experience this winter. I am really excited about getting to sleigh this winter. The two horse experiences topping my list for PEI were riding on the beach and sleighing.


As most of you know, our Ophelia sustained a devastating injury on a back leg on Thanksgiving Day and the prognosis was extremely poor. It was felt by all that it would have caused her great suffering to attempt to fix it and in the end, we would have been putting off the inevitable. So, the decision was made and Gil was with her until the end. Of course, Ophelia was out of my mare, Olivia, and we were there at Dr. T’s when she was born. Alli took care of the farm while Gil and I spent every evening/night at Dr. T’s watching Olivia on the monitor, playing lots and lots of cards, until finally 3 weeks later, at 2 a.m., Ophelia was born. She would have been 3 years this January. This has been extremely difficult for both Gil and I, but especially Gil. He was bonded to her (and her to him); the way Olivia and I are bonded. It is so tragic and sad and we will miss her so much.

Gil started working on 01 September and is really enjoying small town medicine again. He sees patients at the clinic in O’Leary and also has some on-call time at the O’Leary Hospital. Of course, he has beat the “evidence-based medicine” drum since arriving and is now back to doing some teaching. He has just gotten a medical student who will be doing a one month rotation with him. Since he was a hospitalist at S&W the last 8 months or so before moving here, he wasn’t doing any teaching, so he is really enjoying having a student and teaching again.

There are lots of changes in medicine going on here though. For many reasons, they are consolidating services on the island and toward that end, they closed the ER and hospital (acute care beds) in Community Hospital O’Leary, where Gil works. Alberton’s hospital, which is 15 minutes from O’Leary (and closer to where we live), will serve as the local ER and in-patient hospital for acute care and when Gil is on call, he will work out of Alberton. All that sounds good, but we are not entirely convinced that Alberton’s ER/hospital will remain open either. It seems, what would make the most sense, is to have all ER and acute care in-patient in the 2 largest centers – Summerside and Charlottetown. Eventually the only services left in the small communities would be clinic/urgent care. These decisions and changes are very unpopular with the people of these communities, as all the individual communities want their own fully functional hospital/ER, so I imagine these changes are going to come piece-mill and slowly, but I think they are inevitable. So, this makes it difficult to know how to proceed with the horses.

Aside from helping a great deal with this kind of change, Gil is also doing here what he does everywhere he goes, seeing what needs to be changed to make patient care better and setting to work. Providence seems to have led him here for this reason, above all. There are many huge changes which are occurring here and change is something that is difficult for anyone, but it seems especially difficult for the good people of Prince County. The way they have done things in medicine for the past 50 years is being turned on its head and they are being catapulted into the 21st century of medical practice. In so many ways PEI is like the U.S. was in the 50’s and early 60’s and it is refreshing, but not in medicine. It will take probably a good 5 years to really implement these changes and have them running well. For all of you who really know Gil, that will be the time we will be ready to go on to our next adventure…

Willa and Isobel are very happy here. They love the snow, although it is s a little difficult to see Isobel dashing through it as it usually deeper than she is tall!! Lucy bird is great too. It is somewhat cold for her and we have to keep the house a bit warmer than we would otherwise and I keep an oil heater on next to her cage. She seems very happy there though. She is dangling off toys in her cage and talking smack constantly! We also brought Dory, one of our barn cats from the farm. She is now an inside cat, as she doesn’t care for the snow or the cold much!

Gil and I learned what it is to prepare for winter in a north Atlantic region. Everyone here utilizes two sources for heating – oil and wood. Oil is extremely expensive, so everyone uses it sparingly. So, we ordered our 7 cords of wood for the winter. Wood makes more of a warm/cozy heat than oil does as well. Our wood was dumped on the front lawn, 3.5 cords at a time, by the entrance to our basement and we had to get it down there and stack it. I won’t lie – it sucked. I am used to walking over to a thermostat and putting it to whatever temp I would like the house to be. Well, that really isn’t an option here. As our good fortune would have it, Alli and Jesse came for a visit for U.S. Thanksgiving and helped us with the second 3.5 cords. What a huge help that was. Gil had discovered on the first 3.5 cords that he isn’t 20 anymore!! After helping to get 7 cords down to the basement and stacked, I like the thermostat thing even more. Imagine this though – there are 70 and 80 year old men here who stack 7 cords by themselves every winter. Holy cow!

We really like it here though. The pace is MUCH slower here than in the U.S. I will say that has taken some getting used to. I tend to approach most everything with a snap, snap, snap, get it done now approach. You can forget that here. No one is in any hurry ever for anything. There is no such thing as running by someone’s house quickly to drop something off. If you go by, you have to come in for at least an hour for hot tea and conversation! Everyone here loves to talk. Even if you go into a store in search of something and have to ask for assistance, you will usually get at least 15 minutes of conversation before you get the answer. We went into a shop in Charlottetown which has woolen knitted clothing to look for a sweater for Gil – one sweater – we came out about 2 hours later! Even in the checkout line at the Farmer’s Co-op (grocery in O’Leary), a bit of conversation occurs within the check out timeframe (and if you don’t conclude it and move on, they will keep talking while folks just stand behind you and wait – and they will just stand there and wait patiently for however long and listen to your conversation!!) and it will almost always include comments about the weather. EVERYONE loves to make a comment on the weather conditions of the day. In fact, the other day I was sitting at the kitchen table working when I noticed the recycle garbage truck coming down our street and realized I hadn’t yet put out or recycle bags. So, I rushed to throw on warm clothing, grabbed the bags, and ran out to the street just in time. The garbage man, took my bags, threw them in the truck, and then proceeded to talk to me for the next 15 minutes about… the weather!!! He told me all about a horrible snow storm they got in the 1982 and how the snow was almost to the top of the telephone poles and how winters here have been really mild in comparison since… and on and on for 15 minutes. The garbage man even loves to talk! He was very pleasant and we had a very nice conversation.

I will have to say though that the folks we have become good friends with the quickest here are also people from “away”. That is was the locals call folks who move here and are not from the Island, even if you have moved from Nova Scotia. They say, oh you are from “away”! When folks say that to me, I say yep, we are from “way away”, 2400 miles, to be exact! Our good “from away” friends Pam and Jim, originally from Ontario, but have lived many, many places, are headed to Nunavut (above the 60th parallel) for the next year for Pam to work. It is only one year and they will be back, but we will miss them so much. We have had so many wonderful dinners with them and, in fact, that is where we will be on Christmas Day.

Being on PEI has been such a wonderful learning experience and we have only been here a short while. We know what it is like to stand in the midst of a blizzard, drive in one (the first snow of the season was pretty close to a blizzard and I had to drive home from the barn – 45 minutes away!), drive in a mixture of snow and then rain (slicker than poo you’d find in microbiology!) the smell of a woolen mill, the taste of exquisite ADL dairy products, the flavor of fresh (out of the ocean less than 2 hours, boiled in ocean water on the boat) lobster, and what it feels like to stack 7 cords of wood.

So, that about wraps up our year. It has been one of learning, joy, and sadness. We are still at the same e-mail addresses and you can always find what is new in our day-to-day lives by visiting Gil’s blog.

Our stuff is here…..where are the horses

Well, the household stuff arrived today and it is a welcome sight. We were able to cook in the kitchen without having to improvise measuring devices (those little plastic sandwich containers work well in a pinch) and we no longer have the limited choices of sitting on the floor or standing in the kitchen when we have dinner. The guys who unloaded our stuff worked very quickly and got everything off the truck in about four hours. Thus far, the only damage we have found was a dent in our metal trashcan.

In other news, the painting is progressing albeit a bit slower than I would have liked. In the perfect world we would have completed two rooms prior to the arrival of the household goods, but since our world is anything but perfect, I have just finished the second coating of primer on the master bedroom. With luck, I can paint the whole thing tomorrow and we can move most of our furniture out of the other rooms and into the bedroom. That would mean we could sleep in our house, on a bed, how cool.

The arrival of the household goods is not without a hitch. The staircase that leads upstairs is a bit narrow. The house is 100 years old, it is an old New England style farm house, and the stairs are narrow. Come on, it is 100 years old, and beds were smaller then. Our bed, a queen size, was unable to successfully navigate the stairs. The mattress made it alright, but the box spring got stuck, and since we are renting, we did not feel the comfortable pushing it through. So, we have a mattress upstairs, a box-spring in the garage, and one more item on the “to do” list.

Medical News
Now that we have arrived on the island, I am beginning to get the last minute in person details finished in order to legally work, and receive compensation for that work. To bring things up to date, the process of getting a license to practice on the island was far easier and more straight-forward that things were in Texas.

The process involved completing the application for the College of Physicians and Surgeons PEI since they are the licensing authority. This was pretty straight-forward and did not require any complex actions on my part. Much to my surprise, it was relatively efficient, and not too expensive. The attitude of the College is trust but verify, so I have been granted a temporary license until all of my credentialed are verified by the Educational Commission for Foreign Medical Graduates (ECFMG) for PEI.

Again, this was pretty straightforward. I had to complete an application, send some money, and await the verification process to be completed. In less than one week I had received an e-mail from the ECFMG folks telling me that they had received my application, and that it would be reviewed and processed in three weeks. Once this is complete, I am fully licensed.
With all of that rolling along smoothly, we arrive at the last minute details that cannot be completed prior to arrival in Canada. These include things like the application for a billing number, malpractice insurance, and training on the computers at the hospital. The one thing that is currently outstanding is the acquisition of a Social Insurance Number (the Canadian equivalent of a social security number) and we are applying for these tomorrow, as well as squaring away our insurance.

Not bad for a couple of folks from Texas. Now if only our horses would arrive things would be great.

So long and thanks for all the fish.....

Well my time at Scott and White has come to a close. On July 31st I will leave my employment at this fine institution where I have worked for 8 years. I realize that some folks look at 8 years in a place and think ‘Hey that’s a pretty good start’. I have never been one of those people. I do not know if it the youth that I spent moving every 4 years as we crossed the state form job to job, or if I just have an inherently restless streak . Either way, I cannot seem to stay in one place for an extended period of time.

Eight years seems like a long time in my mind, until I look back on what I have gotten done that I set out to accomplish during my time at Scott and White. First and foremost, I completed my Family Medicine training which was my paramount goal. Along the way toward completing that training I got to do some pretty cool things. I got a chance to learn a great deal about teaching through the Faculty Development Fellowship that I took through Waco Faculty Development Center it laid the foundation for what was to follow and without their guidance I could not have achieved all that I have as a teacher. It was through them that I challenged myself to try and become the ideal teacher that I wanted to have when I was being trained, and to their credit I got closer than I ever thought possible. During that process I made some very dear friends whom I will very much miss.

So what was it I wanted to try and change that prompted me to stay for eight years? Well, I wanted to do what I could to help make the Family Medicine residency become the best program possible. Toward that end I was able to make some incremental changes in the way we conducted morning report so that it would better serve the needs of all the participants. I also managed to change the way in which we conducted the Morbidity and Mortality report so that it provided a better teaching moment for all concerned. I was lucky enough to work with Dr Marc Via and through his example became a much better clinician through my understanding and ultimately teaching of Evidence Based Medicine, and it was this step that allowed me to really teach the things I had wanted to understand when I had been in practice in Utah all those years ago in the Army.
Along the way I had the chance to work with many wonderful and inquisitive students that challenged me to become a better teacher. I worked with residents who prompted me to continually stay on top of medical advances through their probing questions about why I chose to do any particular thing. Finally my colleagues who through their gentle rivalry spurred me to improve my medical practice. All of these things were wonderful and without them I would not be the physician that I am today. But their time has passed and the next adventure waits as I move forward to meet those new goals.

So today as I look back and give thanks for all that has been I am excited as I look forward to all that has yet to become.