Firsts make big impressions

March 24, 2026

I’ll tell you a hospital tale

A patient, anemic, so pale.

That we drilled into the bone

For the marrow, his own,

To show where his red cells did fail.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

I have been looking into several cases of anemia in the last couple of weeks.

In the course of explaining to one patient why I wanted to launch an investigation of anemia, I stopped and I said, “Look, don’t get real impressed. It just so happens I read an article about this problem 2 nights ago.”

And then I went on to talk about the first hospital patient assigned to me as a third-year medical student.

At that time, doctors used to hospitalize patients for diagnostic studies.  The docs made money, the hospitals made money. A few years later, insurance companies decided not to pay hospital rates if investigations could be done outside a hospital. 

At a time when we referred to medical texts rather than search engines, I hit the medical staff library.  The investigation of anemia lends itself to a stepwise protocol, which I followed under the direction of the hematologist. I quickly ruled out the common anemias and went on to search for increasingly uncommon diseases. The very last step, a bone marrow biopsy, revealed the rarest of the rare anemias, a disease with 16 syllables.  And which I have never seen since.

 Because firsts make big impressions, I remembered.

While explaining to my patient why I found a simple explanation logically unsatisfying, I had to talk about why the workup of anemia has changed so little.

After the patient exited, the no-show holes in my schedule left me free to research.  In 2026, I can access the world’s largest library from my computer (I can also do so from my phone, but I type faster on a keyboard).  I went to one of my favorite websites, American Academy of Family Practice, and found a new wrinkle in an old algorithm: check for celiac disease.

We’ve known about celiac for hundreds of years, but we didn’t have really good testing till this century. Without proper dietary management, that gluten sensitivity can lead to lots of other problems, from vitamin deficiencies to anemia to malignancies.

Gut upset from grain products does not necessarily mean the person has celiac, because 21st century American baked products use supplemental gluten.

The investigation of the patient’s problem will continue in a step-wise fashion. I put in orders for 8 more tests, but even if those come back normal, I will still have diagostics to pursue. 

And just like 50 years ago, if diagnosis eludes all the other studies, the last test would be a bone marrow biopsy, looking for a 16-syllable disease which might or might not respond to a vitamin. 

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I’m the doctor, not the judge

March 15, 2026

I want to recount here a tale,

About those who succeed and who fail,

Behind bars they spent time

Some years of their prime

Behind bars, in prison or jail.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

I don’t know why, but my facility provides care to many of those recently released from incarceration or transitioning away from prison.

I don’t ask about the reasons they ended up behind bars.  I usually say, in these words, “I wear a white coat, not a black robe.  I’m trained as a doctor, not a judge.  My job is to get you healthy and keep you that way.”

In a previous decade, I also took care of people who had done time.  Despite what Hollywood would have us believe, they find employment easily.  One said, “There’s always a job.  It might not be the job you want, but there’s always a job.”  That person went from hire to shift manager in 6 months. 

I didn’t realize that not only does the state put up bonds to protect employers who hire, but provides tax breaks, and thus subsidizes wages. 

On Friday, the newly liberated constituted almost half of my patients.  Most had recently resided in state prison, but one had been in federal custody.  They came with a variety of serious, chronic problems.  One brought a health synopsis from the prison doc.  That single page showed me what I needed to know in terms of medical problems, past treatments, and ongoing needs.  At first I thought that the physician who wrote it knew how to make a concise summary, but later I realized AI might have been the author.  In any case, it told a story of significant illness, treated in a timely fashion, and needing further treatment to obviate fatal consequence.

Nonetheless my patients showed me the overlap in the Ven diagram between incarcerated, Native American, schizophrenic, and drug abuser. 

I found a stark contrast between two people in the same reentry program.  One wanted to talk about unfair rules and bad food, the other quietly related an orderly plan to achieve meaningful, attainable goals. 

One casually mentioned the offense that led to a stretch in prison.    

I admit my curiosity, but I admit it’s idle curiosity.  That knowledge would not change my treatment of the human being in my exam room.

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In memoriam: Liem Som Oei

March 11, 2026

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

Liem Som Oei, the nephrologist, the best doctor I ever knew, died today.  He was an example to all who knew him.  He started at 6:00AM and never stopped before 2:00AM.  He never stopped smiling, he never lost his sense of humor, and he never yelled at a nurse.  He knew more neurology than the neurologists, more rheumatology than the rheumatologists, and more pharmacology that the pharmacists.  He spoke 11 languages when I met him, and went ahead and learned Swedish so he could go on vacation. 

He didn’t limit his knowledge base to medicine.  He knew world history far better than most historians. 

He knew everything and he didn’t act like it.  When you’re that smart, you have no need for arrogance. 

On Christmas night in 1989, when medical records retrieved past paper charts for patients needing admission, I called him in consultation.  I gave Som the patient’s name, and he remembered consulting on that patient 7 years prior.  I flipped down the stack and found the chart for that admission.  Som gave me all the abnormal labs from the initial lab sheet, pausing a second to think for each value. 

Every doctor in town could tell a similar Som Oei story.  We all knew he was the best doc in town and we all knew none of us could compete.  If you could find a reason to call him in consultation, he could always add something important to the patient’s care.

When Som talked, we listened.  If he agreed to speak for a dinner program, the physicians would pack the venue, even with a 3-hour notice. 

A gentle teacher, if he found a mistake in a colleague’s management, he knew how to make that colleague a better doctor without bruising an ego. 

He grew up with Sukarno’s racist repression of ethnic Chinese in Indonesia.  He fled to a Belgian medical school which failed half the students every year.  The outstanding transplant program drew him to the nephrology fellowship at University of Iowa.  A hard-working internist, who did dialysis, recruited him to Sioux City, where he stayed. 

Married to a physician, the couple brought up two children, both now doctors.

Som was a good father, a good husband, a good teacher, and a good friend.  The world will be a poorer place without him. 

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Tuberculosis: some thoughts

March 10, 2026

In places with lots of TB,

They use the vaccine, BCG.

While prevention is best,

It screws up the test,

We apply to the skin, just to see.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

When I joined the Indian Health Service in 1982, I made it clear I looked to the IHS as a career, not as a pay back.  The service unit where I worked, the Acoma-Canoncito-Laguna (ACL) IHS hospital, needed a TB control officer.  I volunteered.  They sent me to Denver for 3 days of really first-class training. 

Over the next couple of years, they sent me for updates. 

My father still worked ER in Denver in those days, and remarked that he was seeing a resurgence of a disease that the US had pretty much gotten past. 

And when we look at the rates of TB infection, we can see a steady decline that preceded successful drug treatment.  A good portion of that improvement came from architecture; as prosperity spread, people had better ventilation and less crowding.  After WWII we had good drugs to treat TB.  Yet the rapid drop in TB death and disease did not accelerate with the advent of anti-tuberculous drugs.   

In a different century at a different facility, I took the assignment of a patient with multi-drug resistant TB and Wernicke-Korsakoff syndrome.  The TB germs in his lungs could survive a combo of 3 drugs but not 4.  Alcoholics run an increased risk of TB, and severe alcoholics risk losing short-term memory for ever.  He couldn’t remember anything for more than 30 seconds. Under such circumstances he had to be hospitalized for 60 days, for supervised, inpatient treatment. 

One of the Native facilities in Alaska faced an outbreak of tuberculosis during my short 12-week stint.  At that point, treatment of TB had changed, but the demographics hadn’t: it disproportionately hit the marginalized, living in crowded conditions. 

Testing for tuberculosis has changed.  We still use the skin test, but we also use the blood test, Quantiferon Gold.   And we still use the chest x-ray to tell us about contagiousness.

Because TB is not all that contagious.  Upton Sinclair, in his novel, The Jungle, talks about how TB germs could live for weeks in the moist, unsanitary conditions of Chicago’s slaughterhouses.  While true, such microbes can’t infect humans unless aerosolized.  Cousins of TB live in soil, but very rarely infect people.

All the germ in that family have a wax capsule.  They derive their resistance to treatment from that wax capsule and slow growth. 

My experience with TB will help me at my new gig.  The country has a growing homeless population.  Many of them have overlapping diagnoses of severe mental illness and substance abuse. 

We also have immigrants from countries where the chance of tuberculosis runs high enough that vaccination with BCG justifies the complications it gives us in diagnosis.

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I don’t like finding high-value pathology

March 9, 2026

I really would rather the thrill

Of telling someone they’re not ill,

That they might be curious

But the findings aren’t serious,

And we’ll try a low-hazard pill.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

People don’t come from the ends of the earth to our humble corner of Iowa without stories of drama and irony, odysseys of danger and intrigue.  However much I want to ask about such journeys, I don’t.  Because I have my hands full listening to what’s wrong today. 

I started the day with 11 patients on the schedule, of whom 8 arrived.  I don’t know about the others, but I’m sure their stories would fascinate me as much as the stories that I elicited. 

Because I have decades of personal experience dealing with chronic pain and auto-immune disease, I go looking for diseases that I hope not to find.  Yes, we have wonderful treatments, and superb diagnostic tests, but, all-in-all, I would really prefer to set down a sheaf of papers that I’d just explained, and say, “We’ve done all the reasonable tests, and so did the consultants, and whatever you’ve got, however much it bothers you, it’s neither serious nor grave.  Now what we do is work on the symptoms.  What bothers you the most?”

I didn’t get the chance to say those things today, instead I had to say, “Well, I’ve gone over the lab and imaging, and things are definitely not normal.  Most of what I’ll be looking for is treatable, but not all.”

Tomorrow, I’ll have to talk to two patients and say, “You know what we said about the most serious diagnosis?  What you have is serious but treatable.  We can improve your symptoms but it will probably take 10 years off your life.”

I’ll have to tell still another that we have truly miraculous treatment that will cost a million dollars over the next decade, and the specialist can’t be accessed for another 4 months if we’re lucky. 

Our facility has a marvelous polyglot patient population.  We have interpreters for Spanish, Vietnamese, Somali, and Amharic. For all the roughly hundred others, we rely on the telephone language line.  Not nearly as good as speaking the language myself, at best it helps communications.  Probably the worst, but unavoidable, use of language lines comes in the diagnosis and treatment of a sexually transmitted infection acquired during a marriage. 

I do the best the I can. 

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COVID strikes again

February 26, 2026

From experience I feel I can speak

The start, we saw, was the peak.

The wave that was first

For me was the worst,

And I can hope that COVID grows weak

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

I have had muscle, joint, and bone pain for so long that it wasn’t till Sunday, when the shaking chills hit abruptly after supper, that I realized I was sick.  In short order, my temperature (on a mercury thermometer) had gone to 101.5, and I felt terrible.  My cough, never gone since first COVID in 2020, didn’t get much worse but I had to work harder to get the sputum to clear.  I broke into our generous stash of COVID and flu test kits.  Sure enough, the COVID side showed positive, the flu side showed negative.

I broke down a couple months ago and got a pulse oximeter.  I could report to the phone nurse at the VA that my oxygen saturation was 94%, not realizing that their protocols demanded a visit to ER if below 95%.  I know how desperately busy ERs can get at night, especially on weekends, and I declined to go immediately.  The nurse promised to call my VA outpatient team first thing in the morning. 

Promptly at 8:00AM I called the VA outpatient clinic.  An hour later I spoke with a live nurse and expressed my frustration, not so much at the long wait (unavoidable) but at the annoying hold message saying, every 18 seconds, that my call was important.  In less than 3 minutes she approved an ER visit.

Monday morning, as it turns out, rarely brings high patient volumes to most ERs.  I got in and out in less than 2 hours, came home and went to sleep.  Bethany picked up my medication shortly after.  By 6:00PM, with Tylenol, Paxlovid, and ibuprofen, my fever broke and I felt better.

I have had COVID at least 6 times, possibly 7 or 8.  I lost count. I have had the COVID immunization 9 times, to the point that I’m a connoisseur of jab administration techniques.  The mRNA vaccine is about 50% at preventing COVID but 95% at preventing hospitalization and/or death from it.

After 3 days of Paxlovid, I’m feeling better.

I try not to substitute personal experience for robust clinical data, but I think that each round, COVID infection gets milder.  Perhaps all those shots have improved my response to the disease, perhaps all the disease has improved my response.  But maybe, just maybe, the virus is getting weaker.

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Lyme disease, and new Swedish and Somali vocabulary

February 8, 2026

It comes from the bite of a tick

The spirochete can sure make you sick,

But the tick needs a mouse

And a deer near your house

Tetracycline can sure do the trick

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

I got my first undergraduate degree in Anthropology in 1972 and entered a very limited job market.  I could go further in the field to embrace academia, but the biggest employer of anthropologists at the time was the CIA.  Back then, that organization supported the Vietnam War.  They would have sent me into the field with interesting cultures, to learn the language and customs so that if we entered into military action, they would fight on our side. 

Throughout my medical training, I knew I wanted a cross-cultural experience for myself and my children.  I combined my undergrad training with my medical credentials and a recognition of the terrible wrongs done to our Native Americans and spent 5 years in the Indian Health Service.

I still identify as an anthropologist, but I don’t have to fight for grants or publish papers.  And I don’t face housing, food, or employment insecurity.  Day to day, I get to study the people I work with and the people I serve.

Northwest Iowa turns out to have surprising ethnic diversity.  Our facility has interpreters in more than a dozen languages.  In the short 10 days I’ve been attending patients, I’ve worked with people speaking Oromo, Tigrinya, Somali, Haitian Creole, Spanish, Arabic, Swedish,  and English.  A number of patients had more than one language; some had 4 or more.  The combination of fluencies startled me. 

My Spanish served me well.  My French, though weak, brought smiles and strengthened the bond with the patient.  Saying thank you in Somali helped establish rapport. 

I found out that Swedish for thank you sounds like the Somali command for get out! Both pronounced  tak.

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One summer in the 90s I saw 32 cases of Lyme disease.  I called up the County Health Department to report each one, and every time had the report refused on the basis of absence of Lyme disease in Woodbury County.  The clinical data (typical symptoms/bullseye rash/abnormal blood tests) did nothing to break into the circular logic.  Not even the history of tick bite in another state. 

This week, however, I called the Health Department to report a case.  My long-standing friendship with the person who took the report helped. 

Yet it’s the wrong time and still the wrong place for Lyme disease.    

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Possible complications of common infections.

February 4, 2026

There once was a doctor named Jones

Who heard about fevers and moans

From infections by strep,

And the very next step,

Is to look it up on our phones.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home

Still low on the electronic medical record (EMR) learning curve, I had 4 patients on my schedule this morning.  Two canceled. I ended up seeing 5.

The less I judge my patients, the more energy I have at the end of the day.  Everyone knows the bad things about tobacco.  All know heavy drinking brings more illness than light drinking, few appreciate that alcohol has no safe dose.  Even an occasional drink doubles a woman’s risk of breast cancer.

As always, I can’t give details on specific patients.  

I poached most of my patients from Urgent Care.  Two had serious illnesses, one requiring the Emergency Room and admission to the hospital. 

One had a physical finding I’d not seen before.  Medicine has always been a team sport, and I remain a generalist.  Still, even in the days of GPs doing surgery, I would have sent that patient to a specialist.

More than one of those seeking my services today had been to other doctors for the same problem.  The quote attributed to Sir William Osler (a paragon of Victorian age medical care) runs: “I strive not to believe what my patients say about my colleagues, though I fear it might be true.”  I really don’t know what the patient said to the other physician, nor what that physician said back.  And the physical examination always changes, even over the course of a day.  Nonetheless, I like to think I listen well.  Certainly, keeping my mouth shut and my ears open gave me valuable diagnostic clues today. 

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In 1932, my mother had strep throat which led to scarlet fever.  In an era before penicillin, strep throat could lead to severe complications.  She was quarantined with her grandmother for 2 weeks, during which time her linguistic skills broadened.  But the illness damaged her mitral valve, and she had a distinctive murmur for the rest of her life. 

Strep remains a common infection, but the complications have faded to obscurity.  I remember learning about the Jones criteria for making the diagnosis of rheumatic fever in the 80s.  I haven’t seen a complicated strep infection so far this century, and I don’t know if I did today.  In previous years I knew which textbook to pull down.  After a half-hour with online sources (if you must know, OpenEvidence, UpToDate, and Wikipedia), I knew that the print info would have been obsolete.

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Everyone knows: no aspirin for kids

February 2, 2026

My patients?  I can’t tell you who,

But I can say it’s the season of flu.

I cannot say ‘Golly!’

In Oromo or Somali,

But I know how to play peek-a-boo.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home.

After almost 2 weeks of orientation and some really excellent Electronic Medical Record (EMR) training, I got scheduled for patients at a reduced pace. 

I can’t give details about individual patients, but I can speak in generalities of the human condition. 

I have skills with yoyos. Not quite good enough for a tournament, I still rate in the bottom half of the top 5%.  Children from all backgrounds like to watch the spinning toy.  I use it to quiet the frightened and to engage the recalcitrant.  I don’t have to know the word for yoyo in Oromo, Tigrinya, or Somali, I don’t even have to know the word for toy.  I used the language line to converse with a parent while I played with a yoyo and established rapport with the patient. 

Children too small to relate to a yoyo still like to play peek-a-boo.  I have acquired a few fine points of the game, but most of them have to do with mirroring the patient’s facial expression, followed by an exaggerated smile. 

Influenza in the northern hemisphere follows a predictable yearly course.  The epidemic starts in the north and proceeds south. In a given city, 85% of the cases happen in the course of 3 weeks.  If a person has 2 known flu contacts in the house, along with fever, cough, and aches; whether or not they have headache, eye pain, vomiting or a positive flu test, I will strongly suggest treatment with oseltamivir.  If that person has a reason not to take that drug, I’ll push for one of the alternatives.  And I’ll talk about the risks of using aspirin in the context of influenza. 

I only saw 2 cases of Reye’s syndrome, where the liver turns to mush and the brain swells (both happened in other states and before 1985; one died and one recovered).  A serious but rare complication of aspirin administered to children during influenza, it has essentially vanished.  Within 6 months after researchers discovered the causation, everyone knew not to give children aspirin. American media got the message out faster than the medical establishment could.  Few remember that aspirin was a mainstay of influenza treatment for almost a hundred years, fewer still know why we stopped its use.

While flu gallops through the community, we have another virus sickening hundreds.  It starts with sudden onset of vomiting and diarrhea, dehydration and muscle cramps follow.  Weakness persists for a week or more.  That initial presentation usually points to food poisoning.  The context points away from that diagnosis. 

The treatment remains the same: fluids to maintain hydration. 

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25th or 26th, depending on how you count

January 21, 2026

For EMRs, I’ve sure paid my dues,

And I hold it’s my right to refuse

Any system with complicity

With that system, Centricity,

That gave me such a case of the blues.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa.  In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand.  After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I worked telemedicine, a COVID-19 clinic, a VA clinic, and spots in Texas, Iowa, and Pennsylvania.  This summer, I got rescued from a war zone.  After getting down-sized from circuit riding rural clinics, I have taken a position close to home.

In the late 50s, my father dictated his office notes with a reuseable wax cylinder called a Dictaphone.  At that time, however, most docs were keeping hand-written records, some on file cards. 

In my last year of residency, I clerked (now we would say ‘scribed’) for the dermatologist in Casper, Wyoming, writing his notes in real time. 

I still wrote clinic notes long hand in the Indian Health Service, till 1987, although I typed up the first note (the H&P or History and Physical) if I hospitalized a patient. 

My private practice used microcassette recorders and transcriptionists till 2006 when we got an Electronic Medical Record (EMR) system, driving one partner into retirement. 

Throughout the country, doctors now spend 1/3 more time doing records than they did before computerization, which, effectively, reduced the amount of time available for patient care.

Depending on how you count, in the last 11 years I’ve learned 25 or 26 new EMR systems. 

One of my first locum tenens (travel) gigs brought me to a hospital using 3 different systems: one for the hospital side, one for the clinic side, and another previously used in the clinic.  They retained the third only for information retrieval. 

Two years ago in Western Pennsylvania, I used a system with an identical name to the system I’m learning now.  But the vendor made significant changes since, and installation of the system varies widely from facility to facility.  Which brings the question: how different do 2 variations have to be for one to get counted as new? 

I have used 3 good EMR systems.  New Zealand’s national, MedTech32, stands as a paragon of usefulness and simplicity.  DoctorOnDemand had a very good proprietary system for telemedicine but they replaced it.  MedExpress’s DocuTap worked well and quickly, but I don’t know if they still use it. 

One, Centricity, I found so horrible I quit the job, and after that refused employment with any facility that used it.

The system that has occupied this last 10 days rates in the top 40%.  Our shop stands on the verge of rolling out systems using cell phones and Artificial Intelligence and might speed up the documentation process.

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