After reading her the number, I finally got the car keys. As I put my bags in the trunk I got a rush of stale cigarette smoke. The driver’s seat didn’t smell much better; the smoke had taken up residence in the upholstery. I couldn’t bring myself to go back to the counter. Instead I drove one and a half hours with nausea and a low-grade headache, navigating down congested I-95 to Dover, Delaware. When I tried to clean the windshield, I realized there was no washer fluid. “Why is my life so hard?” I quickly derailed the self-pity train. “Are you breaking rocks by the side of the road with a baby strapped to your back? No? Then zip it and be grateful you have meaningful work.” This is my usual internal dialogue when I feel sorry for myself.
On the road to the Residence Inn in Dover, I passed strip malls and fast food restaurants, liquor stores and check cashing services, a casino and racing track. The place reeked of hard luck and bad choices. I felt a wave of sadness, not unlike my reaction to Las Vegas, minus the glitz and glamour of dancing fountains, crystal chandeliers, and Rat Pack nostalgia. I would spend the next week in Dover, and I would return the following five months for a week at a time. This was my introduction to life as a locum tenens physician.
Locum tenens is Latin for “Place Holder.” It is a term employed for a doctor who is hired on a temporary basis—a sort of medical migrant worker. There are any number of reasons a hospital or group employs a locum tenens physician. Perhaps one of their doctors is on medical or parental leave. Perhaps someone takes a sabbatical or leaves the group abruptly. Jobs are often in places that have difficulty recruiting or retaining physicians. In Dover, the orthopedic group had recently lost a surgeon and physician’s assistant, and the lone hand surgeon was overbooked. Patients were waiting weeks to be seen. I was brought on to help with the clinic backlog and deal with emergency referrals. I was only expected to work in the clinic; there would be no call and no surgery. I would work for a week, then spend three weeks in Seattle. While initially hired for two months, I ultimately kept this schedule for five.
My first day I met the physician recruiter at the hospital to get my photo taken for my ID badge. As I wasn’t going to be doing any inpatient or emergency department work, there was no need to tour the hospital. I was taken directly to the nearby orthopedic clinic which was housed in a converted shopping mall. The Blue Hen Office complex contained several government agencies, along with the IT offices for the hospital. The orientation was brief and efficient. Fortunately I was already well versed in EPIC, the electronic medical records software. I was introduced to the clinic and practice managers. Their brusqueness reminded me again of my Philly days. Perhaps it's the standard demeanor of the mid-Atlantic region. The orthopedic clinic was organized into window-less pods with fluorescent lighting and piped-in music. The satellite station was permanently set to the Sirius “Bridge” station, soft rock from the 1970s. It was an endless stream of Eagles, James Taylor, Simon and Garfunkel, and Carole King tunes. While seemingly innocuous, the music would slowly drive me insane. If I hear “Cat’s in the Cradle” one more time…
I am a creature of habit. My first week in clinic I worked with six different medical assistants. Nothing is more inefficient than having to constantly train staff, especially during the course of getting oriented myself. Just when one medical assistant had the system down with rooming patients, a new one would be assigned. The medical assistants were all competent and pleasant, but I grew weary of explaining paperwork, injection techniques, and patient instructions. It will surprise no one that I can be demanding. Eventually I get matched with Becky, who not only took great care of my patients, but also tolerated my idiosyncrasies. We mastered the finely choreographed dance of patient flow so that as to provide efficient and expert patient care.
As a locum tenens doctor, I was a contracted provider. I didn’t work for the hospital or facility; I was paid hourly wages by the company that sent me. It’s not so different from the temp agencies I worked with after college (remember Manpower?) when I worked as an administrative assistant (a.k.a. secretary). On my first stint in Dover, new patients (and they were all new patients) were given ½ hour appointments. On subsequent visits, I requested that new patients continue to be given ½ hour visits, with follow-up patients in 15 minutes spots. I got some push back from the local administration; apparently other orthopedic providers saw all patients in 10 or 15 minutes slots. Some doctors would see 40-50 patients a day. I explained that this would not work for me.
On a few occasions, I noticed patients being placed into 10 minute appointments. I would contact the office manager who would apologize and said it was simply the nature of the “template,” and that they would change it. This happened multiple times over the next few months. It reminded me of one the reasons I left private practice. Doctors are the income generators in the medical system. The more patients we see, the more money the organization makes. The push is for quantity over quality.
Having a manageable schedule makes a world of difference for both doctors and patients. People need time. Medicine is all about making that connection. As a physician I am privileged to get a glimpse into the most sacred spaces of the human condition. I listen to stories and create bonds over small things and large. When we can discuss the beauty of hummingbirds, the best hiking trails, the challenges of care giving for a family member, it creates an atmosphere of respect and trust. As the saying goes, “Patients don’t care how much you know until they know how much you care.”
People share their stories on their bodies, whether pierced, tattooed, or scarred. I saw a man who had a partial hand amputation from a gun-shot injury. Prior to this injury, he had previous hand fracture and had a complex wrist laceration (“someone was trying to steal my bracelet”). He was a healthy man in his 40s but was not working. He was frustrated since could no longer support his family or help around the house. He had once enjoyed fixing cars and maintaining his yard. Now loud noises scared him. I gently asked if he had ever spoken to a counselor after his gunshot wound. Both he and his wife teared up when I brought this up, fifteen minutes into the visit. This was not a question I could have asked at the start of the conversation.
“I done some bad things when I was young. I figure this is just punishment.” I wanted to tell him that’s not how this works. That acts of violence are cruel and random, and that everyone is worthy of love and forgiveness. But I didn’t say this 1) because I am an orthopedic surgeon and talk about how to fix broken bones, not how to fix the spirit and 2) because I cannot presume to speak for his God. But I could provide him care and compassion, and that takes more than ten minutes. His wife was relieved that someone had finally noticed her husband was depressed. Along with the referral for the hand therapist, I included one for behavioral health.
As I had no call or surgical responsibilities, there was no need for a pager and I did not work weekends or evenings. I slept better than I had in a long time, as I no longer worried about surgical complications or middle of the night consults. The most stressful part of being a surgeon had always been the unpredictability, and now that was gone. I led a very ascetic and focused life. There was a refreshing simplicity in being in a place where I knew no one and was free from distractions. I was in town to work, nothing more. The Residence Inn had a functional kitchen, free breakfast, and a fitness room. My schedule was as follows:
5:30 am Wake up, make coffee
6:00-6:30 am Workout in hotel gym
6:30-7:00 am Shower, get dressed, pack lunch
7:00-7:30 am Breakfast in the lobby
8-5 pm Work (Lunch 12-1pm)
5-6 pm Break
6-7 pm Charting/dictations
7-8 pm Dinner
8-10:30 pm TV, read, journal
10:30 pm Bedtime
Once I got used to the routine, I started exploring my surroundings. As Dover is the capital of Delaware (“the First State”), there is an old-timey village green with colonial buildings. I found nearby Silver Lake, where locals fished and families promenaded. I would walk there on the way home, a good way of clearing my mind after a day spent in the antiseptic clinic. I learned that the region was part of the migratory path of birds along the Atlantic Coast. My bird watching reverie would occasionally be interrupted by a low-flying military plane, a reminder of nearby Dover Airforce Base.
On subsequent trips, I found other nature preserves—Bombay Hook Sanctuary, Prime Hook, Killen’s Pond, all replete with waterfowl, marshes, and birders. I mentally catalogued the birds: bald eagles (flying and earthbound), the ubiquitous red wing blackbirds, snow geese, cormorants, avocets, plovers, snowy egrets, and great blue herons. Driving home at twilight, I escorted green turtles across the road and kept an eye out for rabbits and red foxes. My last two weekends I discovered the Delaware beach towns—Lewes, Rehoboth, Bethany. I went kayaking amongst horseshoe crabs and osprey nests around Burton’s Island.
Initially I thought I knew no one in Dover, until I got an email from my college roommate Cindy. It turned out she and her family lived in Dover. Her husband (another college friend) was a cardiologist who had seen my name in the staff newsletter. I hadn’t seen Cindy and Dave in many years, and we met several times during my time there. They helped me discover the better restaurants, recreational sites, and the best market for fresh produce. Dover was small but had everything I needed. After living in Seattle for fifteen years, it was reassuring to know that I could live just as happily somewhere else.
One weekend in July, Cindy and Dave invited me to a pool party at their house, inviting another mutual friend who came up from Baltimore. John was Dave’s closest friend in college and had been my residence counselor sophomore year. John and I had bonded that year over our shared love of American literature, Trivial Pursuit, and vodka. We had many drunken debates about who was the superior writer, Hemingway (John’s pick) or Faulkner (mine). It seems so quaint now that these were the most pressing questions in front of us. John was going to write the great American novel, and having read his writing, I believed him. After college he went to work at an investment firm and then on to an insurance company. He became a numbers man, got married, had children. I went on to become an orthopedic surgeon. Life got in the way of our literary aspirations.
Who could have predicted that thirty years later we would reunite around a kitchen table in Dover? We were all a bit greyer, a bit rounder. But the mannerisms remained. John’s boyish grin was the same, as was Dave’s enthusiastic storytelling and Cindy’s shy sly humor. The music played on Alexa instead of cassette tapes, but the songs were familiar. We reminisced about friends and family we had lost over the years, some to addiction, others to chronic illness or sudden malignancies. We reckoned with the passing of time, suddenly aware of our frailties and mortality.
It would be the last weekend I spent in Delaware. I missed doing surgery and requested to have some designated operating room time. The hospital policy was that I could not operate unless I took call. Ultimately I decided that my aversion to call was greater than my desire to operate. I left my options open, but I sensed I wasn’t coming back. Our lives are a series of choices, paths we follow and those we leave behind. All our situations are temporary and subject to change.
For pictures, Dover
