Getting busier in Buffalo

It's mid-October!

Things are warmer up ... in the practice, I mean. My schedule is beginning to fill up and there are more opportunities for fruitful research collaboration and interesting opportunities to speak to different groups.

I do best when I am busy. I am enjoying being at a university, where there are so many talks and impromptu courses one can attend and further one's knowledge. I'm trying to make my contribution too. I have been able to give a couple of Grand Rounds available with handouts available here.

It feels good to be seeing patients again and doing different clinical activities. I look forward to going to the North American Cystic Fibrosis Conference in Indianapolis, IN from October 31 through November 4. It'll be good to see my old CF Team from Marshfield again and share in the closing of the Fundamental Learning and Leadership Collaborative that I was part of for most of the year. It concludes at the conference with a presentation of the year's work.

Life brings its changes. I shall always have a special place in my heart for the patients, staff and colleagues of Marshfield. Many have now become Facebook, email and LinkedIn friends. I still share in their lives that way. It is also exciting to watch developing friendships and partnerships and professional relationships here in Buffalo. Still lots to do and a lot to get off the ground.

But it's happening slowly.

In the new house!

Last week, on Thursday, September 7, 2017 -- the same day we signed the documents, we finally got to enter our purchased house! It was a busy afternoon, with movers moving boxes into the house till about 10:30 pm. We slept that night surrounded by boxes -- mostly unopened.

This last weekend, we all spent time unpacking clothes, shoes and trying to put together the bare bones of what we need for our daily lives. There is LOTS more to do.

Coming to work, things are getting a little exciting. I now have a web page on the University at Buffalo website as well as a page on the website of UBMD -- the physician group I am a part of. That page can be found here.  There was a meeting today to develop a plan to 'get the word out' about a new physician in the group. This will help build my practice.

Last week, I got to meet Dr. David Holmes, a wonderful Christian physician that leads the global health program for the Family Medicine residency. I hope to get involved with that in the near future too and may be going to Haiti with some medical students and residents over Christmas break.

Week 4 in New York!

Here we are! It is the beginning of our 4th week in Buffalo, NY. Exciting. Living in this hotel (Staybridge Suites), I have learned:

1. I seem to need very little to live my daily lives, in terms of clothes, toiletries and sundries.
2. I sleep on the floor very well (but I already knew that). Where I sleep is in the common area of our 2-bedroom suite. During the day, it is where everyone hangs out. Towards late evening, I clear my little area and make my bed.

We are looking forward to moving into our house this week, and I am looking forward to shadowing Genetics, meeting new faculty at a meeting for the purpose and hopefully seeing more patients than I did last week.

We went to church as a family: The Chapel. I learned once again of a remarkable christian Doctor by the name of David Holmes. As it turns out, he is also the Director of Global Health at UB. We have emailed each other, and possibly will be able to meet in person in the coming week. I look forward to new adventures in global health.

I spent the afternoon swimming with my daughter, Phoebe, in the hotel pool. It was a fun time with just the two of us.

Respect the Patient!

I get angry and frustrated. There is a quote that say, "Don't just get angry! Do something about it!" What am I speaking about?

The center of what I do as a doctor is the patient. Therefore, it follows that listening to my patient, empathizing and trying to understand their concern is integral to caring for them.There seem to be more obstacles to doing this. For example, having to sit in front of a computer and click radio buttons and fill text books and click buttons to meet 'meaningful use' or satisfy some metrics qualification. Having to enter data as 'structured data' versus 'unstructured data' because the system cannot search 'unstructured data' to extract parameters to check off the provider meeting various requirements by payers, QI/QA metrics.

The patient tells a story. The doctor asks questions that add details, catalyzes elaboration of the story. It actually is quite like a story. There is a drama analysis structure called the Freytag pyramid which, simplified, describes drama as consisting of three essential points (with stages connecting them). They are (oversimplified): inciting event, climax, resolution. The clinical case would similarly have a inciting event (chief complaint), climax (acute catastrophic event, point of maximum symptoms) and resolution (cure, management, treatment). In between these points would investigation and evaluation (between inciting event and climax) and management or treatment (between climax and resolution.).

I used to be able to write my notes as narratives with a classic structure of Chief Complaints, History of Present Illness, Past Medical History, Social History, Family History, Review of Systems, Physical Examination, Results, Assessment and Plan. All medical students are taught this.

The structure has not changed, but with the advent of 'structured data', the note reads less like a narrative and more like a series of disjointed bullet points or random phrases grouped under headings.

Patients encounters have changed from being an opportunity for a patient to describe what ails them, into a data collecting opportunity and an chance to 'check the boxes' (colonoscopy? check; Immunizations? Check; Questions about Fall Risk asked ? Check; Depression screened for? Check). I wonder if patients don't feel like instead of having an open window to get a doctor's ear and seek his care, the doctor walks in with an agenda and list of things to do. Won't they feel like instead of listening to them, the doctor has a computer with blanks to fill out in a form, leaving precious little time to actually listen and examine the patient?

I write to create awareness of this quandary. I do get the need for having quality metrics and improving care, but have we become so overwhelmed with filling data into computer programs that we forgot the sensitive precious nature of the doctor-patient relationship? The eye contact, the healing touch (literally), the empathy and connection. The creating of a safe place where a patient will open his or heart and divulge important yet difficult to say information. What of these?

I'm still not sure how I'll do it, but I won't forget:

Respect the patient!

Integrated Care

Coming from Marshfield, WI to Buffalo, NY has introduced me to many changes:

1. In Marshfield, basically, the Marshfield Clinic was a place where most patients got ALL their medical care. That meant that if I wanted to know if someone was up-to-date on their vaccines, or had had a pap smear or colonoscopy recently, I had only to look in the same electronic health record I was accessing as I was seeing the patient. In contrast, in Buffalo, a lot of the patients I saw this week had 'blank' medical records in our EHR. This is because they had gotten their previous (and some current) care elsewhere in the city -- with different medical groups. In order to determine what had occurred there, I would have to request medical records from these multiple providers and the documents would arrive by fax and be scanned as image documents into their EHR in my practice.
2. Marshfield: one central healthcare provider in town with all specialties belonging to that practice (the Marshfield Clinic). Buffalo: a doctor almost literally on every street corner, competing medical groups, specialties spin-offs, stand-alone ambulatory surgery centers not affiliated with a major hospital. Care is dispersed, distributed and in my opinion, fragmented.

Commentary: I would argue for integrated care within a system. Sharing medical records seamlessly and allowing open conversations with practitioners treating the same patients would benefit the patient and improve their care. The old phrase "It takes a village to raise a child" seems to apply here. When I hear the term HIPAA (Health Information Portability and Privacy Act), I feel it means that a patients health information (PHI) is portable. Unfortunately, it does not seem that at all. The Privacy part is magnified in practice so large, I think it hinders communication between patients and their doctors and most often, doctors treating the same patient don't communicate with each other -- either in person or through congregating around a common patient chart.

If I were in charge...

Okay, here's my grandiose thinking. The patient should have a medical record in a common platform electronic format that is in their possession. They take it with them to every appointment with any doctor anywhere (now that's portability). The doctor plugs this structured information into an electronic medical record shell to view it. He/she updates it with their contribution -- labs, imaging, examination findings, consult note, whatever. The record returns to the patient, enriched with data and care that supplements (not duplicates, not ignores) what is already present. 

Alternatively, the government hosts a secure patient database that is accessed securely by all providers and with a MyRecord portal for patients. I believe some countries (Iceland?) already do this. Of course, they have a single payer system too. 

We spend an inordinate amount of time and effort to obtain patient records and then they are in a format that cannot be plugged into our EHR software to yield structured, searchable distributed data (labs going with labs, imaging with imaging, etc).

(Sigh!)

Until this happens, I will continue to try to get medical records from elsewhere and enrich my patient's chart. However, I will also try to canvas my patients to get their specialty care with associates in our multi-specialty group practice, if only because we share the EHR and can speak to each other.

The end of Week 3 in New York

I'm still not very busy. However, I have had fruitful discussions with Genetics about 'shadowing' their providers for a while, to get some of their complex adult patients into my practice. I saw patients this week, and am feeling a little more comfortable with the EHR software. We heard some news this week: our closing date for our house was supposed to be on September 5, but since that is the day after the long Labor Day weekend, it'll probably be on September 7, according to our attorneys (yes, in New York apparently, one needs an attorney to buy or sell a house). My wife is very disappointed by this.

We have however, had a good stay at Staybridge. The breakfast is very good and the facilities have been excellent. Living out of a suitcase shows me (can't speak for the rest of the family), how many things we actually use on a daily basis.That is an interesting lesson.

Beginning of Week 3 in New York

So, 2 weeks ago, on this day, Amy and me were driving from Marshfield, WI to Buffalo, New York. We have been here 2 full weeks.

In this time period, we have managed to get NY state license plates and vehicle registrations, NY Drivers Licenses (well, computer printouts on paper, with the actual Photo ID in the mail), health insurance (through my wife's TA job -- see the Health Insurance post for details) and entry into my office on the 4th floor of Conventus. I also now have a work computer -- a Microsoft Surface tablet with keyboard. I have been able to get credentialed with Kaleida Health, and have IDs and passwords to get into UB and UBMD systems.

Things we are waiting for: to close on our house in Marshfield (possibly scheduled for Sept 5 or 6 or 7...), to close on our house in Buffalo (scheduled for Sept 5), my university ID (told I could not get it till I get my first paycheck), to be able to move into our house (we are still staying in the Staybridge with our household items, clothing, stuff in public storage).

In the coming week, I begin seeing patients on Tuesday. I still have to sort out how functional my work site is for seeing patients of all ages. I do not have a panel of patients yet. I do have business and palm cards that I can hand out and hopefully start to build a practice. Currently, it appears that patients to Conventus will have to pay to park there. Hopefully, we can address that for a primary practice. I  might try to explore ways of putting myself out there to people who work in Childrens, Buffalo General, the Medical School and Conventus itself to see if they and their families need a primary care doc.

We missed going to church today because my wife and daughter have head lice! We don't know where it came from, but possibly, since our daughter joined us this week from staying with Amy's ex in Marshfield and Chicago, and had lots of contact with other kids, we suspect it came from there.

Meanwhile, I am trying to finish courses in Fraud, Abuse and Waste, Sexual Harassment, Violence in the workplace and whatever else HR has on their to-do list for new hires.

I hope to organize things in my office and start working again on my research.

Here we go...

Figuring out work...

So far, working in New York is interesting. I see my first patients on Tuesday next week. I am excited, scared and many other things.

Here is my current understanding of who I work for:

I will getting 2 pay checks -- one from the the University at Buffalo (UB), The State University of New York, as an Associate Professor, and the other as a Physician of the UBMD Internal Medicine Division, a part of the UBMD Physician Group -- a private practice group. However, as part of the being a UB professor, I will also be an attending in the teaching services at Buffalo General Medical Center (BGMC) and the Oshei Chldren's Hospital. I believe both are facilities managed by Kaleida Health. So I had to get credentialed with UB, UBMD and Kaleida Health.

It has been interesting trying to get on-boarded with these 3 organizations. For example, when I brought up the hiccups with my health insurance benefits with some HR folk, I was told, "Oh, that's UB. I'm UBMD. I don't know anything about that." Additionally, each organization has its own slew of compliance and HR courses new employees must do at hire and periodically: things like sexual harassment, violence in the work place, fraud, abuse and waste and other such things. So I have done 3 courses in sexual harassment -- one each from Kaleida Health, UB and UBMD.

Since UBMD pays the larger part of my salary (2/3rds), my primary work is with them. My location is at Convetus, in the UBMD Division of Internal Medicine on the 4th floor. The 4th floor of Conventus is interesting: there are several UBMD Division with clinics there: UBMD Pediatrics, UBMD Neurology and perhaps UBMD Dermatology. There also seems to a UBMD Pulmonary Testing facility. Interestingly, all these UBMD Divisions have separate tax IDs. So collaborating will be interesting.

We are still working on setting up the Internal Medicine and General Pediatrics in the UBMD Internal Medicine Division. The venue is very new and very modern. It is also quite large. I look forward to making it a buzzing and humming locations with lots of adult and kid patients and an environment that is friendly and welcoming to both these groups.

The Health Insurance Story

So here is my perplexing health insurance story...

During my exit interview at the Marshfield Clinic (where I worked for the last 12 years), I was asked if I wanted COBRA since I was leaving. My last day of work was August 11. Since I was scheduled to start work on August 24 -- within the same month, I opted not to get COBRA. In most places of employment, since the premiums are paid in the beginning of the month, resigning in August would provide me with health insurance coverage for the entire month of August. Since I was starting work in August itself at UB and UBMD, I guessed that -- as happens most places -- my insurance would either start on the first date of hire or the first date of the next month, which would be September 1. I therefore anticipated no break in health insurance coverage. This was important for two reasons: it would be nice to have uninterrupted health insurance coverage should something happen and two, it is now punishable by penalty if one is uninsured for a period of time.

I had a benefits meeting scheduled for August 28, but since I wanted Amy to be able to come to that meeting (she has a better mind for numbers and these kinds of things than I do), we preponed our visit to HR (Human Resources). Since Amy was to be a Teaching Assistant (TA) during her math graduate program, we thought we could discuss our benefits together.

The night before our appointment with HR, Amy and myself were reading the Welcome Packet that UB had sent me through Dr. Ann Curtis' office. We were shocked to discover that there was a 42-day waiting period between date of hire and when health insurance would start! There was no explanation as to why this was. This would mean that my family and me would be without health insurance coverage for that period and would either have to buy insurance on the Marketplace or purchase tail coverage (COBRA) through my previous employer at about $ 2,000. We were both surprised, shocked and rather upset at this, since no one had mentioned it during the entire hiring and onboarding process. We also found that for the plan we were deciding to go with, health insurance for my family would cost $ 185 per pay period.

The next day, we brought up our concerns with HR. The representative said that this was University Policy and there was nothing we could do about it. Interestingly however, my wife, as a TA was also entitled to health benefits. This would kick in immediately and our entire family could be covered for $ 95 per pay period -- less than half of what I would have had to pay. It also did not include the co-pays I would have to make for each doctor's appointment.

I was surprised to learn that my TA wife could get health insurance immediately, while I, a provider of healthcare and a University at Buffalo faculty could not. Furthermore, it appeared that although she paid less than half of the premium I would have had to pay to insure the family on my insurance plan (through the same carrier), the benefits, coverage and co-pay were actually better.

Of course, I am confused. I was brought up believing that if you paid more money, you typically got more goods or more value, since you paid more. I was also led to believe that faculty paying a higher rate and in a better pay grade within the same university system would get better benefits. Apparently, this is not so.

I declare here (for those who do not know) that I believe that some (at least rudimentary) healthcare should be provided by the government from our taxes. The US has the highest per capital expenditure on healthcare and ranks 37th on healthcare quality in the world. It is also the only developed country that does not have government-provided healthcare. Instead, we focus on healthcare insurance, making laws that mandate everyone to carry insurance and subsidizing health insurance policies through private vendors by paying the subsidies to the vendors so that the premiums may be 'affordable' through the marketplace. What ends up happening is that insurance companies raised the premiums for their previous, paying subscribers and increased the amount of deductables so that most reasonably health folk now pay higher premiums and pay for whatever little healthcare they require out of pocket (because they have not met their deductable). Who wins? The insurance companies -- who are businesses and cannot take a loss if they are to continue to stay in business. Who loses? The poor saps who pay a premium, pay for most healthcare out of their pockets (until they have paid several thousand dollars in deductables).

Yeah, I am not a fan of this system.

Almost the end of Week 2

It's been a while since I last wrote. In the interim, these events have transpired:

1. Got health insurance
2. Got a Microsoft Surface computer from work to use
3. Assigned an office on the 4th floor of Conventus building
4. Met the staff of the UBMD Internal Medicine division at Conventus
5. Got some training in Allscripts -- the EHR we use here
6. Moved out of Red Roof Inn into Staybridge at University Place
7. Amy's parents have arrived and are living with us in the 2-bedroom suite at Staybridge

The plan today is to go and see the Niagara Falls with Amy's parents -- both from the US and the Canadian side. That should be an adventure.

Day 7 in New York

Today is Sunday. A week ago today, we had gotten in our cars (Amy and me) and drove from Marshfield, Wisconsin to Buffalo, New York, arriving here at about 2:30 am on a Monday morning.

We woke, I had breakfast (Amy had coffee -- she's not a breakfast person, even though I've told her that 'breakfast is the most important meal of the day') and headed off to The Chapel in Getzville (thechapel.com) a non-denominational local church recommended to Amy by one of the workers here at the Inn and also by the COO of Marketing at UB. We found the people friendly and helpful. The service and style of church reminded us of Northridge -- our home church in Marshfield, WI. We enjoyed the worship, the message on marriage and their interest in doing medical missions, particularly in Sierra Leone. Perhaps this will be our future church home. We came back to the Inn. I was able to speak with Ann -- my friend from college whom I had not spoken with since 35 years. It was great catching up. I spoke with my brother, read the Bible for a while.

I do confess: I feel unsettled. We're living in one room in a Red Roof Inn. Our stuff is in Public Storage, stacked one atop another, much of it inaccessible because it's in a box behind other stuff that we cannot identify. I used to be able to walk into a restaurant and recognize a few faces. Now I recognize no one. We still don't have a house to live in, a job schedule. There are so many things to still learn. Although I'm not working, I don't feel like I'm on vacation either. I feel displaced, in between, in transit, unproductive. Anyway, through all this, I am being patient and holding on. Next week, my in-laws arrive and Phoebe comes in from Marshfield. There will be more of us living in this unsettled state. Training for the new job begins -- such as the training is -- a patchwork of hopefully all the orientation and training that I need.Meanwhile, the closing date for our house is September 5. Hopefully, we will actually close on that date and will be able to get movers to move our stuff in the same day. Hopefully, I can take off work that day. It will be Phoebe's first day at a new school. I trust the Lord for grace for all this.

Day 6 in New York

Today is Saturday.

We woke at about 7 am. I went and got breakfast at Bob Evans (like we have been doing daily). When I came back, we went over to our future home to pick up some mail that had arrived there. After that, we went to a mall to buy a sports jacket, some dress shirts and a pair of black formal shoes. It turns out that faculty in New York wear a sport jacket on their admin and research days. I can't say that I care for that, but I will comply...for now. We came back to the room and I read the Bible. We had the room cleaned too. I managed to call and speak with my brother. We had been texting for the last few days.

A college friend wrote on Facebook that she was coming to NYC and then presenting a paper in Toronto. Hopefully, we can chat on the phone. We plan to go see a movie this afternoon -- something to relieve our action-filled and a little stressful week.

We went and saw 'The Big Sick' -- a movie based on a true story about a Pakistani-born comedian who fell in love with a Caucasian American graduate student. It was funny although the tension with his family not accepting his 'American' girlfriend hit a little close to home. I could empathize with their dissappointment at having struggled to come to this country and their hopes and aspirations for their son to pursue a lucrative career, be a good Muslim and marry a Pakistani girl. However, he decided to pursue a career in stand-up comedy, gave up on his faith (used to play video games when he was supposed to be saying 'Namaz' and married a Caucasian American girl.

After the movie, we went out to eat at Red Lobster. We had a wonderful meal, came 'home' (the Red Roof Inn) and went to bed.

Day 5 in New York

We (Amy and I) both got up early today. She had to head off to the Middle School to get Phoebe registered. I drove back to the Northtown Auto Bureau -- the DMV office we had visited day before yesterday. After staring at all my documents for what appeared to be an inordinate amount of time, the clerk finally accepted them. I had my picture taken and was given computer generated temperory license. The real thing will be mailed to my home address in 2 weeks. I'm okay with that. So, yay, I finally have a New York drivers license.

I headed from there to the Public Storage facility where our things are stored. I finished out a formal white shirt and my suit jacket. I stopped at a Walgreens to buy a razor (to give myself a haircut) and some toiletries (the travel size items I had brought with me were nearly gone). On my way back to the Red Roof Inn, I realized that I also needed a lint remover. I found a Rite-Aid and picked one up. I finally made it back to the Inn by about 1 pm. I buzzed my hair, pressed my white shirt and crumpled suit jacket (from being in a suitcase in storage) and had a shower. I then drove to the University at Buffalo South Campus for my appointment to have my Professional Potrait taken. This is a requirement of the school for its web sites. I thought it would be good to do this before I begin work, so that I would not have to take time off for it then. After the appointment, I called the New York State Medical Licensing office to apply for a photographic ID. After being on hold for 20 minutes, that was done. I then drove to Buffalo General Medical Center to meet with Dr. Michael Aronica. He was on call with the ward team and we met on the 13th floor in the team work room. We chatted about coming aboard and he answered some of my questions. I got to sit in on sign-out rounds. Felt good to be talking medicine again.

I got back to the Inn at about 6:00 pm. After sitting around for a bit, Amy and I went to supper at Kabab and Curry -- the same restaurant, as it turned out -- that we ate at when we came for our house-hunting trip. We finally got back to the Inn at 8:30 pm and I was able to update this log.

The work-week is over. Next week, there is some computer training in AllScripts -- their EHR (Electronic Health Record), meetings with Complainace folk, billing folk, an on boarding processing meeting and a Meet and Greet at a UBMD meeting of 250 physicians and administrators. I believe I see my first patient on August 29.

We've gotten some recommendations from folk on some local churches. We plan to go to service at The Chappel this Sunday.

Day 4 in New York

We woke up a little late because we got to bed late. We started the day with a trip to the University to get University IDs. My wife got hers but even though I had a temporary ID, apparently, I was not adequately processed yet in order to get an ID. They told me to come back after I had got my first pay check. It seemed odd but oh well. We were able to open a bank account with the State Employees Credit Union on campus. We then tried to go to DMV. My wife struggled because she could not find her SSN card so we had to go the storage to get her old (before marriage) card and her marriage certificate. We returned and tried to register our vehicles and get driving licenses. Interestingly, even though I had my SSN card and a valid Real ID driving license from the state of Wisconsin, they could not grant me a driving license. This was because my new license had been issued in March and they needed proof that I had been driving for more than 6 months. They asked me if I had my previous license with me. I did not. They asked me to get a Driving Record from the state of Wisconsin sent directly to them. I called the Wisconsin DMV and was told that their Driving Record only included outstanding infractions and the date of my last license renewal. This was unacceptable to NY DMV. Wisconsin DMV had a certificate of clearance that had some information. NY DMV sounded skeptical. Anyway, Wisconsin DMV could fax it over and they would look at it. By then however, it was closing time and they said that they would check the fax tomorrow. So I left without a NY driving license. I feel that one day, if and when I write a book, I should have a chapter called 'Paper Chase' in which I record all my stories of trying to get paperwork done in different countries -- Nigeria, Liberia, Panama, India, the Caribbean, the US.

We then drove to see Radhika and Dharma Iyer. Radhika was in my same class in Panchgani. Of course, she went to Kimmins HIgh School and I went to St. Peter's High School. She was in a girls school and I in a boys school. The only reason we 'met' was that in those days, both Kimmins girls and St. Peter's boys attended the St. Peter's church. We both sang in the choir. I sat in the boys section and she in the girls section, directly opposite. We were both in the choir from 5th through 10th grade, so I guess we 'knew' each other for 5 years. However, other than speaking once at a church choir picnic, we were not allowed to speak with each other.

It was wonderful to see her again -- 40 years later. We had connected on Facebook some months ago and had a nice long chat.

Dharma and Radhika were great hosts. We had a delicious Indian dinner, and she pulled out her guitar and we sang together some of the old choruses and hymns we sang together in the church choir. Radhika is moving to North Carolina in about 6 months. I look forward to seeing more of her and Dharma over the next few months. My first real friend in Buffalo.

We got back home by about 10:30 to 11:00 pm and hit the sack.

Day 3 in New York

We woke earlier today - about 7:30 or 8:00 am. My wife and me had made plans to print the applications to register our cars and get local drivers licenses. We had it scheduled for the movers to meet us at the Public Storage in Getzville at about 12:30 pm.

We both left the Inn heading in different directions -- she to try to get her ID at the University, and me to get my IDs at UB. As I drove from Bowmansville to Buffalo city, I prayed and cried out to the Lord: Hineni! Here I am! Send me! Use me to bring your love, your power, your kingdom reign, your  authority to Buffalo. Use me to dispel darkness, break the chains of the enemy and to bring His Majesty. I shouted 'Hineni!' Loudly in my car as I drove into the medical complex. I parked and went first to Buffalo General to pick up a new hire 'Welcome Packet' and get my Certification of Residence signed. I tried to get my Kaleida Health ID from the Security Office but their office hours were over (it was 11 am and they stopped ID work at 10 am). I drove to Childrens hospital to try to get the ID there, but Security was attending a trauma in the ER.

In the meanwhile, my wife called me in tears. The movers had come at 11:30 am and were waiting for us at Public Storage! Without getting her ID from the university, she turned around to get there. When she did, the office was closed and since she had not been able to go back to the Inn to get the Access Codes for the gates, she couldn't get anyone into the area with the units. So the movers were just sitting around, charging us by the hour while everyone waited for someone to come and open the gate.

By the time I was able to get there at about 12:30 pm, they had got through the gate (someone finally came) and began to moving. I helped move things. In the process, the movers showed us that in the process of packing the furniture into the van, some pieces of furniture were damaged. My wife was not happy. Anyway, we got everything moved into the units (we had to rent an additional 10 x 10 unit because everything would not fit into the two we had originally rented). It was about 6:00 pm. We were sweaty and tired by then.

Once again, the 2 Penske trucks stared at us. Now empty, they had to be returned to the Penske Truck dealer. I got in the driver's seat once again and once again, my wife led the procession. I went over a curb a couple of times, but did not damage anything. When we reached the dealer, we discovered that the tank was only 1/3rd full. We were told that they would charge us $ 7 a gallon to refill it with diesel. So... The procession hit the road again, this time in search of a gas station. Fortunately, there were two nearby. Unfortunately, they did not have diesel! On the third try, we found one and yours truly took on the tricky task of positioning the truck near enough to a pump without hitting it, to fill it with fuel. I can do all things through Christ who strengthens me! Was my rallying cry.

By the time we returned truck one to the dealer, it was 7 pm. My wife's nerves were frayed from the day she had had. I continued to catch myself and correct course from complaining, murmuring or grumbling, even as she cried over the damage to the furniture.

We came back to the hotel, I had a shower and we hit the sack.

I could not sleep! So I got up and worked on this blog. Our plan for tomorrow is to return truck two, try again to get IDs, maybe go to DMV to get our vehicles registered. My wife was planning to go to the buyer's house to look at some furniture she was interested in selling. If we bought it, it could stay right there.

We're now trying to figure out how to get things our of storage for use that we thought we would have in a house before starting work -- things like dress shoes, my medical instruments, which I had packed, important documents for the above processes. I was reminded of the words of the old hymn the other day, and it comes to mind often during this time:

• On Christ, the solid Rock, I stand;
  All other ground is sinking sand,
  All other ground is sinking sand.

Day 2 in New York

Day 2 (or is it still Day 1?) Monday

We slept in till about noon (I think). Now here you might need some background. We bought a house in Williamsville from a nice elder woman who had lost her husband in 2016. We made an offer and she accepted and we paid down the Earnest money. The closing date on the contract said September 5. We explained to her that I started work and Amy started school on August 24 and we'd really like to close earlier on the house. She had lived there with her husband for 28 years and was downsizing and moving into an apartment. She told us that she would be happy to close earlier if she could find an apartment to move into and get rid of a lot of her stuff. In the meanwhile, she was open to the idea of us being able to move our stuff in earlier -- August 18. We had set up movers to come to that property on that day, and have our 2 Penske trucks parked outside there until then. Unfortunately, she became overwhelmed with her situation. Desperately, she called my wife and told her (while we were driving) that she could not have the 2 Penske trucks parked on the street outside her house or in her driveway, and that she definitely could not let us move our household belongings into the house earlier than the closing date, which was not going to stay at September 5.

Fortunately, she agreed to let us park one Penske truck outside the house, while Red Roof Inn agreed to let us park one truck there, while we lived there. So the first order of business for us on our first day in New York as residents was to find a place for store out household possessions us until September 15. After some searching, we found a Public Storage in Getzville and rented two 10 x 20 climate-controlled units. We called the movers and arranged for them to meet us there the following day (Tuesday) to move our things out of the Penske trucks into the storage units.

The other thing to deal with was: where were we going to stay from August 13 through September 5 (assuming we could move in on the day of closing)? Frantic phone calls to UB contacts (University at Buffalo) helped us finally locate at Staybridge where Amy, Phoebe and myself and Amy's parents (who were coming to visit and maybe help with Phoebe and setting up the house), could all stay... At about $ 125 a night.

To end the day, we had one more harrowing task. I had to drive the Penske trucks from Red Roof Inn and Williamsville to the Public Storage facility in Getzville. Now, anyone who knows me knows that I am not the best driver...I am certainly not skilled enough to drive a 26-foot truck with wide turns and other 'trucky' maneuvers. But we had no choice. So my wife drove ahead of me at snail's pace, while I drove carefully (and prayerfully). We made it without incident to the Public Storage late that evening. By then, our fatigue from the late night and events of the day caught up to us and we came back to sleep.

Through the course of the day, I had plenty occasion to practice the lesson of NOT complaining, grumbling, or murmuring. Instead, as I read in my daily reading that morning in II Chronicles 20: 15: "'Do not be afraid or discouraged because of this vast army. For the battle is not yours, but God's." I extended myself, trusting to His grace in driving a 26-foot Penske truck (no big deal for some people, but a HUGE deal for this man).

The first week in New York

Our home was packed into 2 26-foot Penske trucks that drove out of Marshfield on Saturday, August 12, 2017. On the morning of August 13, 2017 at about 10:30 am, my wife and me drove our respective cars out of Marshfield driveway for the last time. My wife had packed our cars with her clothes, some very large paintings in the trunk, so the car was stuffed.

It was a long day of travelling through first Wisconsin, then Illinois, Indiana, Ohio, Pennsylvania and finally New York. During the trip, I listened first to an episode of 'This Week in Virology', then a lesion of Hebrew, then some MKSAP Audio Companion, Cardiology and finally, after 5 pm ( a day of work done), I turned on music from my playlist on my iTouch. I heard tunes in 4 languages (English, Hindi, Spanish and Italian) ranging from Instrumental Western Classical to Bollywood favorites, to Spanish Cumbria, Rock, Salsa, Latin crooners, and Sufi-is tic songs. My car finally crossed over into the state of New York at about 12:30 am. I let out a loud 'Whoot!' Of celebration. I had been able to spend a lot of time in prayer, praying for the this next step in our journey.

Finally, at about 2:30 am, I pulled into the Bowmansville Red Roof Riff at 146 Maple Drive.

During this long drive, I felt the Lord remind me of the passages in the first 5 Books of Moses where the Isrealites grumbled, murmured and complained. I had become conscious of the fact that recently, I had been doing that. When I grumble, I am saying, in effect, that God is not God -- that He is not in control and that what He chooses for me is not the best. I arrived at 2:30 am in the morning to meet my tired wife, filled with this new resolution: I would not grumble. I would not complain or be negative, or murmur.

Looking forward...

I want to write this now -- before I actually begin my work at UB. This way, I can look back at it and if I lose my way, or if I discover a different path.

Why did I leave the Clinic? What is it that I want to do?

Here it is:

1. Improved patient care: I would love to have more time to think about my patients' symptoms, diagnoses and treatment. Sometimes, while working at the Clinic, I felt that the 20 minutes I had in my schedule was just not enough to fully understand what was wrong, or how to treat it. In a perfect world, it would be great to be able to pull up my patient's notes, their labs, imaging and consults and think. The thinking would be active -- consulting the literature, discussing the case with colleagues, even going back to the basics -- their biochemistry, physiology, anatomy. Then, I would come up with a map of diagnosis and treatment and implement that in the short visits, interpreting the outcomes in the light of the plan I had made. I delight in seeing complicated patients: the diagnostic dilemmas, or the patient with that rare condition for which not much literature exists (certainly nothing like a guidelines statement from a professional society). I would love to build a practice of such patients.
2. Healthcare revolution: I make no secret of it: I am not happy with the direction healthcare is taking. Who's driving the bus? Who agreed to this? I would love to see medicine focus on a longitudinal relationship with the patient and make healthcare more than about prescribing drugs and procedures. I would want to 'push back' against the diluting of healthcare provider qualifications and credentials to provide care. In chagrin I ask, "how little education and training does it take to allow someone to provide care to a patient?" The bar seems to be getting lower and lower -- less years of training. I would seek to write nationally about matters like this. I would like to push back against turning healthcare into widget-making and business. 
3. Teaching: My desire to teach is borne from the first two points above. It is a tradition in medicine for medical students and residents to learn in a kind of apprenticeship from practicing physicians. While teaching the procedural skills and the knowledge of medicine, I want to teach attitude, committment and respect for the patient. I think it was Osler that said, "The secret of patient care is caring for the patient." I hear a lot about work-life balance and physician and resident wellness. That's great but what about patient wellness? This is medicine! Disease and illness doesn't come from 9 to 5 on Mondays through Friday's and skips weekends and holidays. To me, this is not a job. It is a committment to patient wellbeing and care, combined with empathy that drives me to want to go the extra mile -- not cut out the inconvenient hours or long days or mental stress. If I can 'infect' the next generation to carry out this tradition that has been what makes the best doctors, then I would have succeeded. 
4. Research: To be a good steward of the gifts and training I have, I am committed to doing research. This will take the form of basic science work -- my passion is bacteriophage and their potential as anti microbial agents. However, to stay grounded in the real world, I want to lead residents and students in research projects that will impact delivery of better care. Studying the problems my patients face and trying to improve their care.
5. Writing: from childhood, I have enjoyed writing. I still do. As I grow older, I would like to write on healthcare. I might also enjoying doing more creative writing -- short stories, novels and plays. Medical Missions: While I like to have one foot in the 21st century, with research and cutting edge patient management, my heart still aches for most of the world that live in poverty with curable and treatable diseases. I would love to help develop healthcare delivery systems that bring basic healthcare to populations that do not have it. I would be willing to roll up my sleeves and be in the front lines in African, Latin America, India, wherever I can make a difference. I would rather commit to a place, giving its 3-4 weeks every year, than go to different places. Unless, I can do something that births a program in one place and then go to another place and do it again. 

Because the Marshfield Clinic has to compete in a healthcare market and is not a university sustained and supported by outside funds, I did not feel it was fair or practical to be able to do these things there. Although, I did mini-versions of these there and am proud that the Clinic does arguably more than some universities.

However, given the academic bent of my interests, I felt the correct place to try to do this is a university.

So here we go...

Saying Goodbye to the Marshfield Clinic...Part 2

So, here's the thing:

Is any of this captured in metrics? Can we measure the trust, the bond, the relationship between a doctor and their patient in any of these 'pay-for-performance' measures? As a human being, isn't relationship above billable actions? Shouldn't it be? I became a primary care physician to provide birth-to-death care BUT in a context of a longitudinal relationship. I don't see myself as a 'service' provider, or a paid expert delivering a product. Ah well, I guess I'm an idealist. I guess the world doesn't work that way. Medicare and Third Part Payers could care less about our feelings, relationships and sentiments...only about measurable, billable activities, products and services.

Sometimes, I feel a little lost because of this mismatch. Is there anywhere or anywhen I could go to where healthcare is contextual and the doctor is a part of community, adding his piece to that of others, building, nurturing and promoting health and wellbeing? (Hmmm... I think there's a Walgreens commercial like that).

Today I am sad. I feel I am leaving family behind as I go elsewhere. The Marshfield Clinic was not a place where I worked, but a place where I lived, built memories, laughed, cried and struggled for my patients. It will forever be a part of who I am (I trained there, after all), and I hope, I shall forever be a part of what it is.

Saying Goodbye to the Marshfield Clinic...

Today was a sad day. In fact, it has been a sad several months...ever since I announced to my colleagues, staff and patients that I was leaving the Clinic to take an academic position at University at Buffalo (UB), The State University of New York.

There were lots of tears during office visits, some outright bawling and some quiet moist eyes and wet cheeks as precious patients strove to maintain their dignity but could not stop the tears. There was a lot of gratitude and tributes in person, on Facebook, through email and in touching cards, often accompanied by a thoughtful gift, sometimes a photograph, sometimes candy, sometimes a momento.

If you're a primary care provider and you feel unappreciated or feel that the care you give matters little to your patients, that you're just another warm body, PCP, 'doc-in-the-box' or whatever, try leaving and see what happens.

I found it interesting that as one patient posted a picture of me standing next to her daughter during a clinic visit, on Facebook, there were loads of replies, comments, likes and hearts. So much for HIPAA, as my patients 'outed' themselves and me as their provider. Of course, due to HIPPA, I could not reply or acknowledge their posts or comments.

I have spent 12 years at the Marshfield Clinic in Marshfield, WI. I came here as a fresh MD, moving here with my worldly possessions in a sedan I called Jenny (because the letters on the license plate were JNY). I came as a single man and set up my Spartan existence in an apartment complex. I am leaving married, with a daughter, and 2 Penske trucks full of possessions.

I came to be an intern at the Marshfield Clinic in the Combined Internal Medicine & Pediatrics program. I had yet to get a license to practice medicine (only given in the United States after one year of internship). I am leaving after being a physician for over a decade, now double boarded -- in Internal Medicine and in Pediatrics, to be an Associate Professor at UB. Life has changed!

Between these two two bookends, a lot of life has happened.

I was privileged to be invited to become the camp doctor for Camp Angel -- a summer and winter camp held for children between 8 and 12, touched by cancer through a loved one. I've had many laughs and tears at the camp and been privileged to be a part of many stories.

I still remember a retiring pediatrician trying to get me to take on adults with cystic fibrosis as patients. Little did I know what a big part of my life and my heart this would become. Our little practice of 3-4 patients has grown to 30 and I've accompanied patients through their diagnosis, treatment and sometimes inevitable and untimely death. There are many ghosts that come to me when I'm alone and pensive. Caring for these precious young people (and some not-so-young) has brought me joy, tears, heartache and heartbreak. Yet, I would not trade it for anything. I've made friends or colleagues as we have battled CF together.

They say that you can measure the passage of time by watching a child grow. As I said my goodbyes, I hugged (and was hugged by) children whose newborn exams I had done in my office. We reminisced about the close misses, the severe illnesses and hospitalization and the celebrations of milestones. I have a precious picture of a young lady who came to me as a single early twenties and brought to my practice in time, her husband and then 2 children. I still remember going through the take-out window at Pizza Hut every Friday (my tradition when I was single) and being greeted cheerfully by her as she handed me my order. One day I asked her if she had a doctor and she said, 'No'. That was how she came to my practice.

I reminisced with one shy pre-teen about how she cried bitterly during every exam in her first two years of life. We laughed at this as I examined her for the last time.

I cried with a patient as we visited his wife in a memory care center, where his wife was now committed due to dementia. They had come to me as a couple who bantered constantly in the office, each other's best friend. During the years, I shared their grief as I diagnosed their oldest daughter with inoperable brain cancer, then watched her decline and die. It bonded us together.

So, here's the thing:

New Adventure!

It has been a long time since I have written an entry in this blog. A lot has happened. I do not want to insult the gravity of the events by simply listing them. Perhaps I will be able to do separate blog posts on them in time.

After 11 years of being a private practice physician at the Marshfield Clinic in Wisconsin, I have decided to embark on a new adventure. I am accepting a position as Associate Professor of Medicine and Pediatrics at University of Buffalo (State University of New York) in New York. I plan to start there in August. Before that, a LOT has to happen: transitioning responsibilities here in Marshfield at the Clinic, selling 2 houses (my wife's from before marriage and our current home) and moving. There is excitement about the new position and beginning at academics but also sadness at leaving behind many patients, friends, staff and colleagues that have been my work family for more than a decade.

I hope to describe more in the days to come.