(For those who care: Rooms 1 & 2 are the basic consultation/exam rooms, I don't have separate rooms for those two acts; Room 3 is T's room, which is moving towards being the procedure room; Room 4 is the phototherapy machine room, which T also usually takes care of now; Room 5 is my back office.)
By this morning, all schools and daycares were announced closed, and even university classes were cancelled. I'm told that there are about the same number of snow days for schools whether you're in the far north of Canada, or the mid-Atlantic region of the US. The difference is how much snow it takes to close things: a few meters in Nunavut, down to a few millimeters in Virginia. I did go to the hospital for my regular clinic in the afternoon. T was supposed to come also (she's updating our database and taking pictures for lymphoma clinic), but she texted me early this morning that she couldn't even get out of her driveway. I ended up taking the metro. I wasn't bad, maybe 45 minutes, but not crowded. Clinic was reasonably full. I suppose partly b/c no one can ever get through by phone to cancel, plus since it's hard to get an appointment, people actually keep them come hell or high water. There were a few no shows & cancellations, but we replaced them with people who showed to book an appointment. I had 6(?) trainees (3 residents and 3 students), so clinic went really quickly, and I got in some good teaching. Definitely worth going in.
Last night, after I got the kids (and Nom) to bed, I wasn't really tired, so I read and played on my computer, and generally relaxed. At one point, I poured a glass of something nourishing, sprawled in an armchair, and looked out the window at the falling snow, our street having a pleasant picture-post-cared glow about it.
Office & Staff. Evil Secretary was actually out sick for almost 2 days. She takes sick days about once every 7-8 years. I came in Monday and she looked green, told me she'd just thown up, and needed to go home. Fortunately we have T on board now. Even though she's here as a nurse, she has secondary duties of filling in when ES isn't here. Also fortunately, it was a little slow, so she jumped in and did just fine. Yeah, lots of small things weren't perfect, but so what, this isn't her primary job and she's only been here a month. ES had initially told me she thought she'd need to come in for 1 day to clean up whatever mess was left, but there wasn't any. Good. Not having reliable back up of ES has always been a slightly worrisome issue for me, but this is another instance of T seeming to work out well.
RAMQ, fighting with. That's the government medical insurance bureaucracy in Quebec. Despite all our complaining (both as patients and providers), they generally get things done with a minimum of fuss. Had a couple of issues that I had to fight with them about yesterday, which is to say had to get on the phone with someone. Doesn't happen often (as best I can tell, most doctors in US spend more time fighting with gov't and/or insurance companies than actually seeing patients), and at least I got to speak to a human being.
The Good. A patient who was falling between the cracks. He has horrible psoriasis, was put on one of the new biological medications with great results when he lived in Ontario. He moved back here, and the requirements are a little different, and I've been trying for > 6 months to get him approved. Discussed with them for 10 minutes, and today got the approval. They generally figure that if a doctor is willing to take the time to call them directly, it must be important.*
The Bad. Only "medically necessary" acts are insured, which is reasonable. (Some of the backstory is not reasonable, but irrelevant here.) For example, a cyst that is not inflamed, infected, or physically troublesome is not covered for removal, so the patient has to pay. They may not like the cyst (or other benign growth), but the world is full of things one doesn't like, and that doesn't mean someone else has to pay for it. Anyhow, removed a cyst from a patient this past summer, duly warned him he'd have to pay for it, which he seemed to accept, duly charged him… and then he complained to RAMQ asking for reimbursement. Last fall they sent me a nastygram, asking for my notes on the patient and my justification. I sent that back, including a direct quote from their manual. They just sent me a letter saying basically, "illegal charge, we're collecting it back from you with a penalty." I spoke to someone who took the info, "and will get back to me." This is seriously annoying, but I am going to smack them down. If I let it go, besides the money immediately involved, it sets a really bad precedent. I've gotten the Assoc. Derm. Quebec involved, and they will help me for the same reasons. We'll win, but annoying.
*More on fighting for patients. It's part of the job. I'd hate to have to do it for every patient. Frankly, wouldn't have time to earn a living if I had to do that, but every 2-3-4 weeks, something comes up and I need to do it. It comes with the turf. Sometimes it really shouldn't be my job on a particular patient, but if he/she has been bounced around enough times, and is sitting in my office, I figure that morally it has defaulted to being my job, and I'll at least take the time for find out who should really be the one to see him/her, and make sure it happens.
We've been having icy rain. At least not a million below zero, but equally unpleasant, plus snarls traffic really badly. It took me over an hour to get home from the hospital last night, a trip that usually takes 20 minutes. This morning the driveway was a sheet of ice, patients were late, and even Evil Secretary was late, which happens about once every 7-8 years.
The fire part? Well T put some instruments in the autoclave (sterilizer - normally Evil Secretary's job), and didn't know she needed to put the wrapped instruments on a special rack/tray first, so the wrappings were touching the hot interior of the autoclave and caught fire. No damage done, but an unpleasant odor lingered for an hour or so.
Unfortunately, it was a cold, rainy night, which might be atmospheric, but not pleasant. The kids were wearing their jackets over their costumes. Otherwise, ours is a good street for trick-or-treat Many of the families really, really do up their houses. Wallstreet was scared of a few of the decorations, and is really too young to understand, so Nom took him home after a few houses. Hedgefund went to a dozen or so. She was a little scared at a few of them, but was okay b/c I was with her. (I was dressed as myself, what with my being so scary I keep myself awake at night for fear I'm hiding under my own bed.) She ran into a few friends from day care and said "hi" to them. (We've been impressing on her the importance of the social niceties, and she's really picked up on that this year.) She actually enjoys giving out candy as much as she enjoys getting it, so after we went out, we sat on our front porch and gave out candy. Some people came up to me, but I redirected them to her. Around 7:30, we ran out, which was around when it is starting to die down (pun intended) anyhow. I think Wallstreet will enjoy it more next year, and we'll probably have the energy to decorate.
Cancer is a scary word, but there are cancers, then there are cancers. The most common form of cancer of any organ system is the basal cell carcinoma (BCC) of the skin. It is also the least serious, and barely qualifies as a cancer. Put it this way, if you could put cancers on a scale of 1 to 100, this is a 1. It grows slowly, and almost never metastasizes. In short, it would take years, if ever, to kill you. That having been said, an oozing ulcer 6-inches/15-cm across is unsightly and unpleasant. *understatement* Still, when they are small, it's fairly routine to destroy them, maybe 5 minutes.
Squamous cells carcinoma (SCC) is a notch up. However, the first stage, "in-situ," also called Bowen's disease, can sit at a completely superficial level for 20 years before invading. And that having been said, nobody could say if a given one will sit for 20 years, or invade tomorrow, so certainly worth treating, but again, fairly routine to destroy, maybe 5 minutes.
Actinic Keratosis (AK) is considered "precancerous," but that too is an exaggeration. Maybe 1:1000 per year will turn into an SCC, but probably 300:1000 will just resolve spontaneously. Again, the catch is not knowing which one will convert. Still, having that risk, Medicare will pay to treat them, but scarcely exciting.
Benign lesions are no longer covered by Medicare, as part of the changes they abruptly initiated Jan 2017. (I don't disagree with dis-insuring them, it was the abrupt and chaotic way they did it.) Since not insured, I can charge the patient for it, and I never object to getting money, but again, completely not exciting.
Short attention span and easily bored. My kids must be rubbing off on me. Okay, I've always been that way. Not sure how I made it this far. That most be why I'm constantly doing other things at the same time: teaching, military, now trying to get into research. Can't really complain even if all I did was sit in my office: it's more interesting and pays better than most gigs, but today just felt totally unsatisfactory.
Taking a day off goes back to when I was in the National Guard and later Reserves. That "one weekend a month (small print footnote: unless we deploy your butt to Afghanistan or Iraq)" applies to the junior troops. Senior leadership is more like "2-3 weekends a month, and some of those will be 3-4 days long." If I hadn't started programming in "extra" days off, I would have been working 26-28 days/month, and getting VERY cranky. Since the 3-4 day weekends would include the Fridays, and even 2 day weekends meant I would be traveling home and arriving late Sunday evenings, it made more sense to take off Mondays instead of Fridays.
Sometime after I got out of the Reserves (on Veterans Day 11-11-11), I thought I should start to work a normal 5-day week. Actually, come to think of it, I had someone sharing my office on that extra day, then she left, so it was a bit later than that. I enjoyed having those long weekends, but somehow felt I "should" work a normal 5-day week. Nom told me I shouldn't. I felt I should. I felt virtuous. I also seriously missed having the 3-day weekends. I told Nom she was right, and cut back to 4 days, keeping the Mondays off schedule. But really, there's a reason most people who work 4-day week take off the Fridays. Too many things are closed on Monday (eg, if I want a lunch date with my lovely wife, most restaurants are closed Mondays).
All that having been said, I am disoriented. It is Sunday night as I type this, and I'm indignant that I have to go to work tomorrow. I'll go in, and be convinced that my hospital day (Wednesday) will be the next day. On Friday, the first day of my weekend, I will keep thinking that that should be Saturday, and not understanding why every place isn't on weekend hours. It's sort of like being jet-lagged. Not the fatigue, just the feeling that everything is happening at the wrong time, but in this case the wrong day. I suppose in a few weeks, I'll adjust, but for now it feels weird.
1. A gentlemen who informed me right up front that he didn't like needles, wanted me to proceed, but said he thought he'd better lie down. Since either he'd suddenly turned albino, or else was about to faint, I thought that was a good idea. He apologized profusely. I told him not to, I was just appreciative that he had the good sense to lie down first, as I don't pick up people over the age of 5.
2. Another excision that I'd planned to take 15 minutes, took three times that long. When Evil Secretary mentioned that to me later, I pointed out that that wasn't bad for something I'd never done before. It was a nail surgery, building on what I'd learned when we brought in the world's top nail expert. Much of stretching one's self involves taking skills one already has, adding in new knowledge, then doing something just slightly different. Do that enough times, and one ends up with a vastly expanded skill set. It just takes a while, keeping calm, and thinking through problems when they aren't going the way one planned.
3. A very elderly lady with a melanoma on her back, who was mostly oriented (but not completely). She chatted almost non-stop during the procedure. Usually that's annoying, but for someone with my interest in history, it was fascinating to hear some of it, such as her father's having fought at Vimy Ridge (in WWI - look it up). Then, knowing that I'd been in the military, she asked me "which war did you fight in, doctor, the 1914 one or the 1939 one?"
This thoughts inspired by a friend's posting (https://jillianpage.com/2018/07/22/
"Retirement," like many labels, seems to be all-inclusive in its description, whereas it really just means "ceasing to work at a certain well-defined job." I think that goes hand-in-hand with defining yourself as what you do for a living (farmer, lawyer, journalist, etc).
Admittedly, what you do for a living, for most people, is how they spend the majority of their waking hours, and often an important part of their identity, but the be all and end all of their existence, if they don't want it to be.
Another reply to that posting (regb1957) gave a good list things one can "do" in retirement. If your health is good, you can carve out another career for yourself, if you want to. If you want to be at the beck and call of someone else that is. Retirement means you won’t have to, you can do things you want to do, when you want to do them. Write a novel; start a business; campaign for xxx rights; get more deeply involved with local politics, whatever.
All good points, but even that begs the question of if we should define ourselves by what we "do" rather than what we "are."
I think in general people retire later when they enjoy their work. As you know, I'm not going to retire anytime soon, having 2 kids to put through medical school (and they are not even in kindergarten yet). Even if that were not a factor, I like what I do, so can't see giving up doing it any time before 80-? 90-? The key is to recognize when you are no longer capable of doing it well, and stepping down at the height of your game (at least when still in good form), not been pushed out for incompetence. In another 10 years will likely slow down a bit, but not stop.
Even that, again, pushes the question of "who am?" to be answered by "this is what I do for a living." As you know, Gentle Readers, I am a professional (in the older meaning of "learned profession") and that does come with a sense of identity more than most jobs, but I get to largely keep that identity even after retirement. I have multiple identities (as we all do), but sometimes have to remind myself that father/husband/family man is as much my identity as what I do for a living.
Started off the vacation with a great show. Montreal is big on festivals. Trying to prove we're a first-ranked megacity. We ain't, but we have fun. All summer there are different festivals: jazz, comedy, movies, etc. This week is Montréal Complètement Cirque ("Montreal Completely Circus"), and last night there was a free show of Phénix (https://montrealcompletementcirque.com/
We went via Metro, which was a first for the kids. They handled it well. Good. They're urban kids, they should be comfortable on the Metro. More comfortable in Montreal than NYC, because Metro here is rubber tired and therefore doesn't hurt the ears. (That's one of the things I no longer appreciate about NYC. I don't mind the bigness and crowds, I don't like noise to the level of phyically painful. Put dang rubber tires on the subways, or otherwise engineer them better.) Not all the Montreal Metro stations are stroller friendly, but I find strollers do fine on the wide escalators. For the stations that only had stairs, we just looked around for some young man looking friendly and reasonable strong to help me carry it up or down the stairs while Nom herded the kids.
Second a metaphorical one. Had a message to call lawyer xxx at firm yyy. Calls from lawyers rarely good. Especially when I googled firm yyy and noted they were "Un cabinet au service des usagers du système de santé du Québec" This is French for "Ambulance chasers." Turned out they were looking for someone to do Medical Expertise for Dermatology. Sorry, folks, but keep looking. One could argue that they are in the service of justice and I should help them, but "service of justice" sometimes is the same as "hired gun," depending which side of the table (courtroom) one is sitting on. It's rather like Satan asking the Preacher Man for help harvesting souls, "because they're sinners and they deserve it." We have an adversarial legal system, and they're the adversaries. Come to think of it, I believe the literal translation from the Old Hebrew of Satanactually does mean "Adversary." It is actually Ha Satan, "The Adversary." From my admittedly limited readings of the Old Testament, Satan is not the adversary of God, but of Man, more of what we would call today (un-ironically), a "Devil's Advocate."
Don't sit in my chair. Really, it's not hard. The chair in front of the desk is mine, it's my office, you don't sit in it. Also, don't move the furniture. I thought carefully about the layout of the office, and the placement, and there's a reason why things are where they are. Don't move them. Not even moving the patient's chair, especially not 2-3 feet backwards. But really, keep out of my chair.
It's rare that a patient faints, but does happen. Super rare that we don't see it coming. Usually they're still in the exam room, I see them looking pale & sweaty, and quickly have them sit or lie down. Rarely they make it up to reception, and Evil Secretary is very good about spotting the signs and running around the desk and having them sit down. Only once that I can think of did someone give no warning. He (she?) was standing at the reception desk, talking, looking perfectly fine, and suddenly went out. Today it was the daughter of an elderly patient. Daughter looked at me, said, "Mom is feeling faint, can I get her some water." I said there was a glass by the sink, while quickly helped mom to sit down… when daughter fainted without warning. She was fine besides being embarrassed, but only second patient in this many years to faint without warning.
Usually I leave for work before the kids are up. I go kiss them goodbye. Wallstreet doesn't even stir. With Hedgefund, I tell her I'm leaving for work and I'll see her later. She nods in her sleep, but is aware I'm doing it. (If I don't do it, she is very upset when she wakes up that I didn't say goodbye to her.)
I start my own office at 0730h, which is earlier than most of my colleagues, but later than a few. The early hours are good for people who want to come before work or school, or are coming off the night shift. (I also take my lunch earlier so that I'm available during other peoples' lunch hour.) I've been debating starting earlier, and leaving earlier (or even - *gasp* - working a few more hours), but not changing anything for the moment. The other day was our monthly cutaneous lymphoma clinic at the hospital, which starts at a normal hour. Time enough for them to wake up. Time enough for them to crawl up onto the bed with me and lie in my lap, holding my hands, and smiling happily at their time with Papa. Time enough for Papa to consider retiring on the spot, rather than break their hearts by going off to work. Lots of "I love you," "stay home with us," "kiss goodbye." Even Wallstreet who isn't that much into being kissed. *Sigh* Keep working until they graduate from Med School, bah humbug.
*Technically should phrase that as "body mass physically weighs maybe 50-60 lbs in Earth's gravitational field."
Commuting: the garage door on my office building jammed (again) the other day. I was going to go home for lunch, but couldn't drive because couldn't get my car out. The concierge told me there was a taxi office just up the street. Went there. Long story short, "you have to get the app to call us." Jerks. I'm standing right there, you have drivers and taxis just sitting around, but you won't take my business because I don't have the "app." Fortunately there was a taxi from another company nearby so I went with them. Borrowed Nom's car to go back to work, then back home at the end of the day to get her and the kids. The next morning took the Metro to work. Not really bad, but just that little bit longer and more annoying which reminded me why people usually don't take mass transit when they have the option to drive: walk to the Metro station, wait for the train, (fortunately didn't have to change lines), go 2 stops, walk from the Metro station. Three times longer than point-to-point driving. In nice weather, if I'm feeling energetic, I might walk to work some days, it would be 30-40 minutes.
Cappuccino: The commercial unit across the hall from my new office had their "soft" opening. That is to say, they were sufficiently moved in that if you walked in, they would accommodate your business, but not fully up and running. It is a bicycle rental/repair shop, convenience store, and café. Not as weird as it sounds. They are on the side of the building that fronts the scenic bike path along the old Lachine Canal. The owner has bike repair/rental place about further up the bike path, but this is meant for higher-end bikes. Also, being on the path is a good location if bikers, joggers, or strollers want a cold drink, a snack, or a coffee. I'm happy to have a place in my building that offers same. I have a fridge and a coffee maker in my back office, but they have cappuccino. Frankly, not the best cappuccino, but it is there. They will have a terrasse outside. Montreal is big on terrasses during our - limited - good weather. Their main entrance is from outside along the path. However, if you live or work in the building, and have key fob for the front door, it will also let you into their store directly from the inside hallway. Very clever on the owner's part, as it makes him the convenience store for the building too.