COVID-19 Tour Day #8

It is the last work day! One of the attendings did not show up so me and another attending split the patients of the floor between us and rounded on all of them. Thank God for residency training that prepares you to deal with increased workloads.


One of the hard parts of COVID-19 care is wearing the P95 mask, face shield, gown and gloves for the hours spent in patients' rooms. However, I have to say that compared to the heat of Sierra Leone during the Ebola outbreak, this is not bad at all.


The day was pretty much the same as the previous ones. One 73 year old admitted to another team a few days ago and on whom I rounded yesterday is actively dying. She had made it clear before that she did not want to be intubated. Her blood pressure fell and she is on BiPaP (at the time of this writing). I anticipate that she may die before the shift is over at 8 pm.


So the COVID-19 week in NYC is over. All that is left is to travel back to Buffalo tomorrow. I am grateful for the chance to experience this and be of service. I have made memories of this COVID-19 pandemic up close and personal as a front-line provider. My feelings are mixed: the world has changed on us with COVID-19. On the other hand, just as in the Ebola outbreak, the toll from COVID-19 directly is not as heavy as the toll from people with chronic diseases not getting the care they need in a timely fashion. Systems are working sluggishly, partially shut down and life has changed.

COVID-19 tour Days #6, 7

I am writing one entry for 2 days. The days have been busy. We have been getting admissions from the Emergency Department -- people with anything from congestive heart failure to generalized weakness to confusion … the typical admissions of a general Medical ward. The only twist: COVID-pending or COVID-positive.


The good news: no-one in my ward has needed intensive care treatment or died from COVID-19. The bad news: wow! We admitted a 31 year old young lady that was quite confused. We did a blood gas on her that showed a pH of 7.64 and a pCO2 of 15! Hitherto, I would not have thought this compatible with life. At the least I would have thought she would need to be in the ICU. I had a hard time convincing my resident that was respiratory alkalosis due to her mental illness and strange breathing. We had to recheck her blood gas. I am proud to say that after all these years of not having done an arterial stick, I got it in the first try after the resident could not get it with ultrasound.


After much struggle, she got an IV. After a night of sleep (thanks to Haldol 2mg), her blood gas was pH 7.4 and pCO2 of 36.


We have had a couple of sad old ladies admitted for generalized weakness and failure to thrive. They live alone. One told me, "the only person I have to talk to is the television. I used to go the Senior Center and play bingo but they closed with COVID."

COVID-19 tour Day #5

We are getting busier... not because of a second wave of COVID-19, but because sick people feel a little more comfortable coming to the hospital. We just got a patient with a triglyceride level of 6000 (normal is less than 150). He was on medication but could not afford it and insurance would not cover it. So he ended up in the intensive care and is now transferred to us. He is, of course, COVID-positive.


The day passes quickly. Rounds take longer because we need to put on PPE for every room, take it off and wash our hands and stethoscopes when we come out and do it all again for the next patient. Breathing through a well-fitted N95 is difficult. If it isn't, then the mask does not have a good seal and is not on right.


I am getting a little tired, physically but more so emotionally. It shouldn't bother me, but it does discourage me: I have met very few volunteers. Most of the doctors and nurses who responded to the call for help came through an agency and are being paid a great deal of money to be here. I, on the other hand, had to take vacation days and because I did not give 60 days notice, will return to give up my research days to see patients to make up for sessions I missed. It's also been a little expensive living away from home, although I am grateful the hotel is paid for. I spend money on coffee, breakfast and dinner and because restaurants aren't open, I end up paying for some delivery too.


Anyway, I remind myself that I am doing this because I am a Christian and I go where I am commanded. God has been faithful. My needs are provided for -- one way or the other, I am safe and I am making a difference in the lives of the people -- patients, staff, others that I touch.

COVID-19 Tour Day #4

Another day on the COVID ward. My impression of Woodhull Hospital in Brooklyn: the hospital seems to serve a very diverse population of mostly poor people. The diversity here is staggering. There are very few white people (to put it crudely). There is a large Puerto Rican population, African American population, people from the islands (Jamaica, especially), Polish (many of whom speak no English though they are in the 60s and above). The doctors (including the residents) seem to come from all over the world. Hearing the nurses on the wards, one hears a number of accents -- several African ones too.


I have been impressed with the severity of illness in the patients here and COVID seems in most of them like the least of their problems. We took off 5.9 L of fluid (ascites) from a gentleman that had alcoholic liver cirrhosis and now hepatorenal syndrome. He needs a liver transplant. The resident (intern) did it with no hesitation. It seems they do so many paracenteses here that most of them are credentialed in the first half of the year. We have a diabetic (HbA1c of 13.6%) who has dry gangrene of a left foot due to occlusion of his distal popliteal artery. He shall be getting a below the knee amputation. Another female -- a 37 year old female came in with a magnesium level of 0.8, a calcium of 6, potassium of 2.8 in tetany. Etiology is uncertain but suspicious for poor nutrition and alcohol use. Another gentleman had bad hypertension that has remodeled his heart. His ejection fracture is 6%! We had a young lady (23 year old) been drinking since 18 who came in with a long QT syndrome (QTC 560 ms) due to taking too much Zofran for vomiting from withdrawals from alcohol. She refused all detox treatment and asked to be discharged in 2 days when we would not give her the sedative medication she wanted.


People come to our ward COVID-suspect. Some leave with their test results still pending, because they are medically well. We had one gentleman who came in with COVID with pneumonia and shortness of breath. He did okay. The time came for discharge -- as he was recovered, but he was still COVID-positive. His 70 year old mother did not want him to return home. He is an invalid (left below the knee amputation, right foot 2 toes amputated, obese, noncompliant with treatment. He refused to go to a hotel or inn or shelter (we would have made arrangements) and because he did not lack capacity to make decisions, we had to send him home.


Walking down the street, taking the subway, I see a dirty city with shoddy people. Yesterday, I saw a mouse pop up between the cement tiles of my hotel parking area? There is sewage visible in the sewer.


I have seen NYC. I know that every place is not like this. But it does make me sad to see how people are at least in this little part of town.


The hospital could use more staff, doctors, nurses, facilities. They are doing the best they can with what they have.

COVID-19 Tour Day #3

It was good to come into work today. Yesterday was Memorial Day and today is the first day of work for most people after the long weekend. I have been walking around with a temporary ID and hope to get a real one today. I am also down to my last set of home scrubs and hope to get scrubs from the scrubs machine on the 9th floor today.


I began to day by checking in with Dr. Z -- the Chair of Internal Medicine. After a brief welcome, I got my wish: I am assigned as the Attending Physician of 8200 -- the COVID ward! I shall spend the rest of my tour here.


Excitedly, I got my PPE and headed off to meet the team. I have a nurse practitioner, Judy Osuoha and an internal medicine intern (soon to be become a second year), Felix Filias. That's it: the 3 of us managing a 3rd of the COVID ward. We started out with 8 patients and got a 9th before the day was over.


Our cases were all interesting. They all had COVID and... One patient had renal and liver failure, another a gangrenous foot, another advanced SLE and so forth. There were some medical mysteries which were fun to tease apart. Nobody dying (yet?).


The day went by quickly.


I should say something about Brooklyn and Woodhull. It is VERY diverse: the doctors, nurses, patients and people out on the streets have so many different accents, languages and ethnic origins. A patient I saw yesterday spoke only Polish and we struggled with a phone interpreter who could not make out what the patient was saying as his speech was slurred from alcohol. I happily chatted in Spanish with several of my patients. The place is a little global community.


So far, I feel well. I have intermittently had a little cough and some nose sniffing but these symptoms resolve. Lots of hand washing and putting on and putting off PPE. Reminds me a little of Sierra Leone, but not as bleak.

COVID-19 Tour Day #2

Today is May 25, 2020. I came to work at 8 am. The first thing we did was go through the admissions that happened overnight. Everyone is of course, tested for COVID-19. Since we have run out of the rapid tests, they all got the PCR test, which takes 2-4 days to return results. Until then, they are considered PUI (patients under investigation).


Of course, what strikes me is that COVID or no COVID, people get sick and usually what you end up treating is not just COVID but COVID and...


We admitted a lady that had a blood clot is her lung (pulmonary embolus). She became progressively hypotensive and we had to put a central line in her in the ED. The procedure went well (no complications). Her blood pressure began to stabilize.


The saddest patient of the day was a homeless guy found naked on the street and unresponsive. I learned that he was frequently brought to the ED where a shot of Narcan would wake him up and be would become combative and belligerent. This time was no different. The ED was going to discharge him when he had a seizure. It is possible that the seizure was due to withdrawals from any one of several substances he uses. COVID status pending.


Another patient had a GI bleed and CHF exacerbation and possibly COVID-19


I was at the hospital until 8 pm. 12 hours of work. Let's see what tomorrow brings.

COVID-19 Tour Day #1

It has been a long time since I wrote anything. Life happens. In April, 2020, I received a phone call from New York State asking for physician volunteers to assist New York City with their COVID-19 crisis. I was asked if I could assist at Woodhull in Brooklyn. Well, at first my work said I could not go because they did not know I would be needed in Buffalo should cases rise abruptly. A month later, I got a second call. This time, after some negotiation (I would have to take vacation and because I did not provide 60-days notice to move patients, I would have to make up the 4 clinical days -- 8 sessions -- that I would be missing), I was allowed to go.


I flew into La Guardia airport catching a flight from Buffalo and going through Dulles, Washington, D.C. The flight, fortunately, was paid for by United who generously donated air tickets to the NYC COVID-19  crisis. I was also put up in a hotel (Hotel Indigo in Williamsburg, Brooklyn) thanks again to the generous donation of the hotel line to the cause. The only chagrin was finding out that some of the people here had come through an agency that paid them for their shifts wit hazard pay (numbers like $ 5,000 a week) while the rest of us physician volunteers worked for free.


Today was day 1. It was May 24, 2020 -- a Sunday and part of the long Labor Day weekend. I entered the hospital at 8 am for my 12-hour shift. After a tour by Michael Kopusov, I got to hand out with one of the 'floor teams'. I looked at charts. About halfway through the shift, I found out that my assignment for tomorrow was to be the Admitting Attending. There would be a team of admitting residents working with me. So for the rest of the day, I followed Michael and assisted with the admissions of the day. Everyone got screened for COVID-19 although it seems unlikely that any are going to be positive. One patient had a PE (pulmonary embolus), another had a diabetic foot infection (osteomyelitis of a toe), another CHF exacerbation. All of these are common Internal Medicine admissions -- remains to be seen if they came in COVID-19 flavor.


I got to see some of the patients that came in with COVID-19, in their 20s, 30s and 40s that had to be intubated, ended up getting a tracheostomy, one awaiting placement in a traumatic brain injury unit because of neurological sequelae to the disease.


All in all, this seemed like a good first day -- not too crazy -- and I am a little oriented to the hospital and its system. Epic is reasonably intuitive and since my residents do most of the notes and orders, I am spared the sodded details.


Well, this blog post was interrupted by a Code Blue on a COVID-19 floor -- a 60-something male who just returned from surgery. Fortunately, he had return of spontaneous circulation (ROSC), is intubated and in the unit. A good outcome considering.

Ode to a (dead) cocaine patient

I haven't written for a while. Sometimes I wonder if the long daily hours of being a care giver in primary care may make me jaded. 'Just another day in the office...' so nothing to write about.

On Wednesday evening, as I was winding down paperwork before the Thanksgiving holiday, I got a text message from our Nurse Practitioner covering the phones. The police had called and asked if I would be willing to sign a death certificate on one of my patients. She had been found dead in her apartment with a crack cocaine pipe beside her and foaming at the mouth.

As I put the phone down, I replayed in my mind the first time I met T. She looked older than her stated age, was edentulous, only partially dressed. She shook her hands and yelled, "Help me! Help me! The pain, doc! I can't stand the pain! My hands are burning!" She would sob and cry and shake her hands. Occasionally, she let out a loud expletive. I saw that she had a fleshy mass with a slender stalk attached to her front maxillary gum line. She did not know what it was. She complained of feeling hot and 'burning up' and began to take off her clothes till she stood almost naked before me. I confess, I was overwhelmed with this new patient in an acute state.

I learned that she was diabetic and poor control had led to crippling peripheral neuropathy. She reported that neuropathic pain agents did not help her at maximum doses. She told me she resorted to cocaine because it made the pain bearable.

I remember prescribing her narcotics and getting her set up with a case manager and a social worker. The next time I saw her, she wore a wig, had come with a case worker and seemed calmer. Under local anesthetic, I excised the flesh mass from her maxillary gum line. She was surprised it did not hurt and pleased with the appearance.

Over the next few months, I watched her appearance transform as she felt we were making progress in her pain management and symptom control. She would come in with a wig on, make-up on her face, a set of dentures in her mouth, properly groomed and dressed. She would laugh and speak calmly. Although she was on a couple of narcotics, I felt we were getting somewhere. Her HbA1C began to improve. Her case manager helped her get into counselling, attend meetings to deal with her past.

I learned that T ran away from home at 16. Her maternal grandfather had been sexually abusing her. On bad days, she would cry in my office and tell me, "Doc! I can still see those hands in my dreams. His hands, doc! He would come into my room at night and put a hand over my mouth, and grope me and rape me. He told me that I told anyone, there'd be hell to pay." She ran away from home and became a prostitute. She became hooked on cocaine. She had a son and was now a grandmother. She raised a good boy, she told me.

There were ups and downs. She had several admissions for delirium, psychosis and respiratory failure due to overdoses with cocaine. I discontinued the prescribed narcotics. The old T came back: "Doc! The pain! I can't bear the pain! Give me something, doc! Give me something for pain!" I had nothing to give her that would work.

After her last hospital stay, she had enrolled in an addiction program. She had promised me that she was done with cocaine. She wanted to live for her grand-daughter, whom she loved. I would see her every month and haltingly, she seemed to be coming along.

Until the text message. T is dead. Anger welled up in me as I attempted to address the needs. Yes, of course, I would sign the death certificate. Yes, goodbye.

Who killed T? Was it the maternal grandfather that raped her repeatedly till she ran away from home? Was it the predators in society who took advantage of a young black girl's body? Was it the pushers and pimps that turned her onto cocaine? Was it a system that could not provide her resources to manage her diabetes? Should we hold T responsible for 'poor choices'?

Yes, officer, of course I will sign the death certificate. Yes, thank you. Have a good Thanksgiving. Goodbye!

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.