I have been doing Zoom visits for my former primary care practice in Bucksport since I left there in 2019. I do a Suboxone clinic one night a week for a group of patients who may be in a group therapy session in person at the office or may be zooming in from their homes. The relationships formed in these virtual visits as often very strong.

The pandemic made this type of doctor visit mainstream and blurred the definition of what actually needs an in person visit.

Another example of virtual relationship is my own way of communicating with my lady friend who lives 35 minutes away from me.

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Now, I am blessed to do more and more of my follow-up visits using the technology of video visits. And we are adding new technology to let both our doctors and our patients listen to heart sounds together in real time, for example.

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When I started out, most specialists were in private practice, as were most primary care doctors. Fresh out of my residency, the specialist consultants I referred to were obviously a little older than I. They were well established, made good money and were their own bosses. The grace in their lives was obvious to me.

Their consultation reports were typed on delicious, thick, often colored, stationery and signed with flair, often with a fountain pen. If I called them for what we call “curbside” advice, they were gracious and never seemed rushed. They took pleasure in sharing their knowledge with younger colleagues like me. I’m sure they also expected our referrals over time to be better and more appropriate.

Times have changed. Most of the specialty practices were bought up by the hospitals and specialist doctors became employees with a little less control over how their day went. I could tell when I called for advice that they had tighter schedules than they used to. Many of them also had less help in the office than they were used to having.

The other thing that happened over time was that, since they were all older than I was when I began practicing, one by one, most of them have now retired. The new generation of specialist isn’t as easfor me to call for curbside consultations because we don’t have as much history with each other.

My new practice has a subscription to a nationwide service that I was late in starting to utilize, but now I am hooked. I go to the service’s website, type my question and the clinical background, import labs or imaging reports and, typically in half an hour or less, get a helpful reply from a specialist with at least comparable credentials to what I was used to years ago, and often from somebody with an academic background.

I have received no-nonsense, real-world guidance with a urine culture growing enterococcus faecalis, with a case of Todd paralysis and once got ammunition in the case of an elderly cholecystitis patient with a cholecystotomy tube my local surgeons didn’t want to deal with.

I am now telling my patients here in this physician shortage area that I have almost instant access to specialists and subspecialists my patients would have to wait many months and travel hundreds of miles to see. This sometimes lets me handle more things myself and at the very least it helps ensure that my patients will get the right treatment while they wait for their “local” consultation here in Maine.

My practice actively encourages its doctors and nurse practitioners to use this service. This is such a time saver and worry reducer for both us frontline clinicians and for our patients.

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I palpated my patient’s neck and armpits, listened to his heart, lungs and carotid arteries. I checked his legs for edema and checked his pulse at the ankles. Then I said, “now I need to check your belly, where do you want to lie down?”

He looked over at his sleeping dog and then slowly got up from the couch and proceeded to lie down on the carpetless wood floor. He wasn’t the most agile 65-year old male, but he did it, and I probably did a better abdominal exam than if we had done it in his soft couch.

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Friday afternoon at the outer edges of my housecall territory I saw a new patient who hadn’t seen a primary care doctor for many years. He came down with pneumonia a few weeks ago and went to the emergency room.

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Yesterday, the last Friday of January 2024, I made housecalls in and around Fort Kent, an hour north of where I live in Caribou. There was snow on the ground from a snowfall a few days ago and midday it started to snow again, so much by early afternoon that I was grateful for my studded Nokian tires and all wheel drive.

There’s something very levelling and equalizing when Shelby, my Health Advocate, and I drive up in a snowfall to a house far off the main road in my fancy Mercedes SUV, knock on the door, kick the snow off our boots, step inside, take them off and enter the house of a new patient in our stockinged feet.

It shows respect and it puts us in the same category as when a friend stops by. It is an act of humility that symbolizes both that we are polite guests and that we are not rushing through our visit, but settling in for a one hour visit.

If fire, ambulance or police crews show up at a home, they just walk in, but a primary care housecall is different. It is not a disruption, it is a scheduled meeting with the purpose of learning about a patient and their life and social situation, of building trust with another human being and offering a gift of explanation or a solution to a medical problem.

In your stockinged feet, you’re suddenly humbled in a way. I am reminded of the Japanese custom of leaving your shoes at the door and bowing with your hands held together. I recall “The Devil Wears Prada” posters and I compare that with a mental image of Jesus washing the feet of his disciples - because, in our culture, since ancient times, feet seem to be our lowliest body parts.

My mother in Sweden always used to tell me to wear clean underwear in case I ended up in the emergency room, but, of course, if you’re in a car accident or have a stroke, who knows how clean your underwear will be anyway when you arrive at the hospital. But these days, I do make sure my socks match and have no holes.

My happiest times in medicine have been times of change. I loved being a medical student and a resident. I loved being Medical Director in Bucksport, Maine, where I designed the logo, wrote the patient newsletter, mentored nurse practitioner students and new clinicians, did staff education and introduced walk-in services, helped design a massive building expansion, helped start a Suboxone program, formalized bidirectional handoffs between primary care and mental health and helped bring about many other changes. We were always changing, never resting on our laurels. I led by example, working every Saturday for several years to get the Saturday walk-in service going.

As a foreigner I had heard the word linchpin now and then, but never bothered to learn what it meant. Yesterday I learned it is the little pin that keeps my lawnmower wheels from falling off.

It is also a worker whose efforts hold things together, even though it may not be obvious how indispensable their function is. Seth Godin has written a book titled Linchpin, maybe I’ll check it out. It sounds like for a while I was a little bit like that in Bucksport, but they have obviously survived without me.

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My onboarding and start with Galileo medical was slow and gradual because of the lengthy contractual period of notice with my previous employer, but after several months of part time work for both and some breathing room around the Holidays, I now have only two jobs instead of three. I still do my weekly Suboxone clinic with Bucksport Regional Health Center via telemedicine. This is the Federally Qualified Health Center in Maine where I was Medical Director for most of my career, the place where I helped start the Suboxone program, Saturday urgent care walk-in, bidirectional warm hand-offs (medical to behavioral health and behavioral health to medical), where I helped design their biggest building expansion, where I published their patient newsletter, designed the logo, which was eventually tweaked to be more inclusive but kept the enveloping apple, the place where I mentored half a dozen nurse practitioners and so on.

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I don’t think it matters so much how we celebrate the new year, just as long as we pause and reflect, in case we need to make some course corrections. And as long as we celebrate the symbolic new opportunity that a new year brings.

As an only child in a family with a relatively small social circle, New Year’s was never a big hullabaloo when I was growing up. In my late teens, I was a scout and part of a group that wanted things to be more rugged. We hijacked the American name, Explorers,and dressed in green overalls with an emblem painted on the back, and one of the things we did was celebrate New Year’s by hiking in the woods in the snow regardless of the temperature. We had army tents, very similar to the one in this picture and there was a little stove in there, but of course you still needed the most expensive sleeping bag you could buy in those days. I still have mine. When I have had to sleep in the horse barn on cold winter nights, I have resorted to using that, I still have mine, bought in 1970. Pretty amazing durability.

Fast forward to the 2000’s, black tie, multi-course dinners with dancing at Chateau Frontenac in Quebec several years in a row, and now home cooked Swedish holiday meals with children, grandchildren and girlfriend right here in Caribou, Maine. We cook together and eat the traditional Swedish holiday foods and we may play some silly games. Then we melt soldering “lead” and pour it into cold water and analyze the shapes created, which are supposed to foretell the next year’s biggest events.

All three ways to celebrate are good, there is a time and a place for everything.

So, if you’re reading this, thanks for joining me on Substack, where I started posting about 9 months ago, and where I have found a bigger and steadier readership than I had on Wordpress.

Happy new Year!

Last year, I didn’t write anything about the New Year’s Holiday until two days after the magic moment, and all I wrote was this:

I had this long New Year’s post planned but… Sometimes a picture is worth 1000 words. I am where I’m supposed to be. I’m looking forward to 2023. Happy New Year!

So this year, I am posting the same picture, which is now hanging in the south facing enclosed porch you can see in the foreground of the picture above.

I had pictured white wicker in that room, making it feel like summer year round. But then I ended up with too little space for the Swedish furniture that had been sitting in the house downstate. So my year round summer decor gave way to dark, heavy early 19th century (my guess, I grew up helping at my grandfather’s auction house and antiques store) hand carved rustic furnishings from the old country.

Bear with me, I will tie all this together after the next picture.

My reflection here, as I write this Friday evening, December 29 (with my kids and grandkids still in Bangor because of the icy roads today) is that we may have one vision of the future, but that may not be the only possible good outcome. And the white wicker came to mind because this house is so lovely in the summer. But it’s really just as cute in the winter, which seems a lot longer here in northern Maine. The underlying vision was to make this porch-turned-room a place to linger in. The color scheme and the weight of the furniture may be opposites, but the effect is somewhat similar. And I’m probably happier having my old stuff in this room than something new, or new to me, if it were antique wicker.

Similarly, I started out in medicine with fairly concrete expectations of what I would want things to look like. But I ended up working in a few different settings, sometimes because I went looking and sometimes because opportunities suddenly appeared and I was able to decide quickly to accept.

One of the books I moved around as I was organizing my new library is titled Emotional Agility - Get Unstuck, Embrace Change, and Thrive in Work and Life, by Susan David, PhD. She certainly picked a catchy title, and the 11 chapter titles are equally intriguing:

1. Rigidity to agility.

2. Hooked.

3. Trying to unhook.

4. Showing up.

5. Stepping out.

6. Walking your way.

7. Moving on: The tiny tweaks principle.

8. Moving on: The teeter totter principle

9. Emotional agility at work

10. Raising emotionally agile children.

11. Conclusion: Becoming real.

In many areas in life, we may have a pretty good idea of what we want things to feel like, if not exactly what they would look like. But if we focus too much on what we want things to look like instead of what they feel like, we may stay stuck because our own imagination can’t visualize the opportunities that unexpected things present us with.

Dr. David encourages us to be in tune with our feelings, and I agree wholeheartedly. I have let my head navigate sometimes - over the objections of my emotions. I haven’t done any of the personality tests people talk about these days, but I know that even though I love logic and reason, I am often guided more by my emotions. And Dr. David talks about when to follow your emotions and when to superimpose your mind to keep them in check.

So, in 2024 I hope to be even more emotionally agile than I have been before, finding an even better balance between my heart and my mind.

And I am still where I am supposed to be. Who would have thought that a whole new way of working as a doctor would open up right here in Aroostook, Maine. And that I would be the first one to join.

Happy New Year!

Reflection and update from my new life…

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Sometimes, because I was actively trying not to feel burned out, I saw uplifting or thought provoking things in my ordinary patient encounters that I might have missed if I hadn’t resolved not to sink into despair about how things work in medicine today.

Less than a year after I started this blog, I left the clinic where I had spent most of my career, where I was Medical Director and originator of all kinds of improvements and program expansions, even a major contributor to a massive building expansion design. Then I started over, from scratch, at age 56 in Van Buren, a part of the state where nobody had heard of me.

Writing helped me through the difficult time of not yet having an established reputation and position, and it helped me see everything as a new opportunity; if nothing else, this big move gave me something to write about.

Life happened, my marriage ended (early followers may remember many, many posts about the good days) and primary care changed. To an outsider it may seem petty or even pathetic that a physician might leave their position because of its computer system, but I know for a fact that the EMR is a common and important consideration for physician applicants when considering a new practice.

And this year, I knew I had to do something different. And there, suddenly, was a LinkedIn message from a Galileo recruiter. Housecall practice, first in Maine, backed by a large organization, large territory. I, who put 300,000 miles on my big SUV driving back and forth working on the coast and in the north woods, used to joke “If it paid better to drive for a living, I might want to do that”. Now I drive and make housecalls. Seems like I manifested this life change.

So, I’m starting over, at my age.

And this year, my new lady friend, a retired grade school teacher, returned to work part time and is now the official, full time third grade teacher in Van Buren, where she grew up. She tried being retired, but decided to do more, to start over, doing what she loves.

And last night, after half a year playing with Substack, a bigger platform for my writing than my own little blog, destiny knocked on my door, it seems. I’ve had the same theme (template) for my page design since 2008. WordPress announced years ago they would not be supporting it. But it always seemed to work – until last night. All of a sudden, all you see on a laptop or an iPad is the masthead and the sidebar on regular blog pages. Fortunately, the iPhone still displays everything. The words you are reading right now are not a blog post but a “page”.

So, I could choose a new theme, but that means my masthead would have to have different proportions and all kinds of similar fuss…and the viewership on a day to day basis is multiples more on Substack. Plus I even get occasional paid subscriptions (in case I eventually decide to slow down in my clinical work).

So the more I think of it, the more I think I might just park the WordPress blog and concentrate on Substack. A freestanding blog is almost like when wife #1 (don’t ask) had a BBS, a dial-up bulletin board before the Internet, with only one or two viewers at the same time and she, the “Sysop” (systems operator, I think) chatting via text with them.

Substack is more like YouTube or TikTok, a platform where readers follow their writers but also get glimpses of other writers they might also want to follow.

So that’s the way I feel tonight, two days before Christmas the year I turned 70. All fresh and new. Age is just a number.

But being invited to spend an hour with a new patient in their home is more than just a longer routine, clinical appointment. It is an inversion of the usual doctor-patient relationship. In an office based practice, patients visit me in rooms that reflect what I can do, like the visible medical furnishings and equipment, or have done, like the diplomas on the wall. In a housecall, my patient is the host. I have fewer accoutrements. I very clearly feel like a guest. And as a guest I usually try to bring something you might think of as a gift.

The gift I bring is not a “thing”, and I’m not even sure that most patients perceive it as a gift in that moment. But I have found they often speak of it in such terms as we wrap up the visit or the next time I see them.

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Checked out Galileo Maine’s brand new, winterized mobile exam room: All wheel drive, extra insulation and heating, motorized exam table, generator, satellite Internet (Starlink), even a private bathroom!

I couldn’t figure out how to do that. So I left.

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The more eye contact we have in that first visit, the better start we get off to in our relationship – Hans Duvefelt, MD

Some practices won’t see a new patient until their old records arrive. My new practice doesn’t work that way. I’m very okay with that.

With few exceptions, I find that most patients have a need to tell their story and I appreciate the opportunity to hear and react to that story in real time. For details they can’t provide, I reassure them “we’ll get that from your old records”, or “we can check that with the pharmacy”. In Maine, there is also the state database, Maine Health InfoNet.

That first conversation between doctor and patient sets the tone for the rest of our relationship. It is when each patient starts to figure out how much they can trust your interest in them, your knowledge about their medical condition and your respect for their past choices and current priorities.

In each such initial conversation I try not to interrupt more than absolutely necessary.

In my reaction and mirroring back I also make sure to weave in something that deepens my patient’s understanding of their medical condition or their medication – without seeming overly confident, but more showing that I have a genuine interest and experience to bring to the table.

I might tell them how their disease was first discovered, how their treatment was invented or how many different approaches there actually are.

I make very sure to listen for each patient’s priorities. This ranges from long term health goals for their chronic conditions to why they are bringing up new symptoms.

One question I often ask about new symptoms is “are you worried this is a sign of something dangerous, do you want it to go away or are you just wondering how your body works as far as this sensation goes?”

My initial housecalls are one hour long, just like many office based specialists and twice as long as my colleagues’ in office based primary care.

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Seeing patients in their own homes gives you insights that an office visit, or even several office visits over long periods of time, can’t give you. From the pictures on their wall to the food in their refrigerator or the soundness of their house or the steepness of their driveway from their mailbox to their front door, you learn things about them that no amount of questioning in the office can teach you.

My first house call of the day he other day was right in town here in Caribou, on a street I have driven many times from Sleeper’s store to downtown. It was in a brick apartment building I never reflected much on. Stella Brown met me and Courtney, my assistant, in the lobby and pressed the buzzer to unlock the front door. She escorted us down the hall, past a dining room and seating areas to a very industrial looking elevator with gray wall-to-wall carpet on the walls.

“That’s unusual”, I said and touched the carpet, “a padded wall”.

“I know, this was the old hospital, Cary Memorial Hospital”, she explained, “built where Dr. Jefferson Carey’s home once stood”.

That’s who the current hospital on the Van Buren road is also named after. It was built in 1978. The building I was now learning about was completed in 1924, twelve years after his death.

“My apartment”, she added, “is on the top floor, where the maternity ward used to be”.

We got out of the elevator and passed a sun-drenched seating alcove. It is shared between all the tenants on that floor, she explained. She unlocked her apartment door and I entered a large room that could have been a delivery room almost a hundred years ago. Strangely enough, the building and her apartment didn’t feel that old; I would have guessed late 1940’s to have been its vintage, but that’s probably splitting hairs for anybody much younger than me.

Our visit was uneventful besides the history lesson I got out of it. But my second visit that day had more drama and actually gave me a chance to feel heroic.

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One Morning in Maine (that’s a famous children’s book, at least locally), I set off to my new office in Presque Isle. There is a fairly dense fog as I leave the house at 7:30. I usually don’t have to leave this early, but on this day I am scheduled for a mask fitting, with COVID still a close reality.

I didn’t want to go through Caribou in the morning traffic on Route 1 to Presque Isle with lots of stops for red lights, so I am following the Grimes Road along the northern shore of the Aroostook river to Fort Fairfield. As the fog slowly lifts, I see more and more of the river and the foliage. I pass Rocking S Ranch, where there are groups of boarded horses eating round bale hay in the nearly barren fields. My own horses probably wouldn’t eat round bale; I left them munching on second cut hay, an almost rare delicacy here in northern Maine.

Going from Fort Fairfield toward Presque Isle, I don’t turn right on my usual weekend shopping road that would bring me past Lowe’s to a fairly busy part of town, but continue past Amish country with more horses in the fields and some shackled to buggies standing outside the farm houses. In Easton I turn right and eventually pass the small hospital in Presque Isle and then turn onto a side street before I even see the very first traffic light on my journey and I actually arrive at the office in less time than if I had taken the busiest road through town.

My first house call for the day is an hour away, close to Houlton. I see Edwin Starks, a man with multiple medical problems and spotty medical care. Halfway through our one hour initial visit I know that he had been misdiagnosed and that he suffers from an iatrogenic condition (an avoidable disease caused by his previous providers’ misguided medication choices).

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