EMRS I've done twenty-four,
I'm surprised it hasn't been more
They make patient flow
Really, quite slow
But at five, I walk out the door.
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 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska. Since the pandemic, I did telemedicine, staffed a COVID-19 clinic in Iowa, worked at the Veterans Administration in South Dakota, held part-time positions close to home, worked 10 weeks in western Pennsylvania, had a 5-month assignment in Northern Iowa, then several months of telemedicine. I am now in Texas, a big place with a lot of Spanish speakers.
We drove into town at sunset on Easter Sunday and spent the night in a chain hotel. In the morning I walked into a very nice facility in a small town in a very large state. To protect the privacy of the patients, I won't name the municipality.
I spent the morning in orientation, including 2 hours on the medical record (EMR) system, my 24th new one since 2014.
Experience being the best teacher, I got assigned 3 patients for 3 hours in the afternoon. When one failed to keep the appointment, I took a walk-in.
After months of not being able to touch my patients, I basked in the relief of face-to-face medicine.
Presented with a puzzling skin problem, I said, "Please keep talking. I have the feeling in the next two minutes you'll hand me the key to the mystery." And, indeed, that's what happened.
This morning I arrived to find 16 patients on my schedule. I remembered outloud my private practice years, with paper charts and transcriptionists, when 36 patients constituted a reasonable schedule.
Except it didn't. I spent 6 ½ hours seeing patients, but after supper I would dictate notes for 2 hours.
Today I ended up seeing 12, and one of my colleagues took one when I fell too far behind.
Most places give me a week before I start seeing patients at that pace, but the stimulus put me onto a faster learning curve.
In med school I learned about Charcot sweats: people wake in the middle of the night drenched in a sweat so profuse they have to change bed clothes. If that history applies to a person with weight loss and a low-grade midafternoon fever, we were taught to look for serious pathology in the chest. But at the same tame our teachers said we wouldn't see it because tuberculosis had almost disappeared.
TB started making a comeback, especially in inner cities, shortly before the turn of the century. It never really left the Native American populations. I held the position of TB control officer for two different Indian Health Service facilities. No surprise that I consider that illness in a wide range of patients.
CT scanners had just appeared on the medical scene about the time I started med school in 1975, fragile machines hooked to mid-70s computers, prone to frequent outages.
I also had cause to remember but question the teaching that a blister on the ear drum (medicalese=bullous myringitis) only came from one germ, Mycoplasma. I went to the net after clinic and found that, in fact, it can be caused by strep or a number of viruses, including RSV.
Treatment decision depends on clinical context. The problem will go away by itself, but it might take 2 weeks.
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