MY CAREER IN MEDICINE
Medicine was the ideal career for my Asperger’s mind. Evidence-based scientific thinking suits us very well. When things were not known for sure, common sense based on a good understanding of medicine took over. It was a job where I could be my own boss. I was never very good at following other people’s orders. Medicine is one job where one must be a life-long learner. I learn things easily by any method. I love to read.
With a great series of lucky occurrences, I started my general medical practice when I was 24 and retired at 53.
With two children and a family to support, it was obvious that I needed to find a general practice to work in. I answered a few ads in the British Columbia Medical Journal. One interview was not a good fit, but I then drove out to Castlegar to interview with a 6-man group of GPs and got a job. This was easily the luckiest decision of my life as rural family practice was ideally suited to me.
Along with another smaller group, we served a population of about 7,000 in town and another 7,000 in the surrounding villages that were speckled on the valleys along Pass Creek and the Kootenay and Columbia Rivers that meet at Castlegar. There were no specialists. However, my group was composed of a bunch of very independent doctors who avidly encouraged partners to acquire special skills. One partner did a lot of general surgery, one gynecology, another internal medicine, and three gave anesthetics. We all did obstetrics, emergency, pediatrics, psychiatry – the entire scope of medical practice. I replaced a short-term locum who left me little practice. That was another good break as I did not get locked into someone else’s patients. Another doctor was hired two months later, but he replaced an elderly doctor who was retiring. His main interest became geriatrics.
We were a very progressive group. It was mandatory to take nine weeks’ holidays per year and have a day off each week to compensate for all the calls we had to take. Later when I did five one-month locums in the Canadian Arctic doing dermatology, I used one of those months each year. I used my day off as my therapeutic abortion day.
Once, all six of us spent a weekend at a retreat to improve how we related to each other. I learned that I was the least influential person in the practice. Asperger’s has always affected my expressive language. I couldn’t talk anyone into all my great ideas.
One issue is that I didn’t have the greatest bedside manner. However, I was able to develop a large general practice of patients who appreciated my competence and liked a straight shooter.
I will detail all the special interests I was able to develop, not to gloat, but to show how my brain on override could function.
Obstetrics. I had a lot of obstetric experience in medical school and internship and loved delivering babies. My very first after I started practice was in the middle of the night delivering a patient for one of my partners on holiday. It was undiagnosed twins (routine ultrasounds were not done back in 1977). I delivered the second breach twin with Piper forceps. No worries.
Eventually, I delivered everyone on their side, a position called Sims left lateral. Careful control of the perineum was paramount and this made it much easier to achieve. Leaving with no episiotomy or at most a simple midline scar made recovery so much easier for women.
I would do any method and did LeBoyer underwater deliveries, even though I really didn’t believe there was any advantage.
My wife was made for having babies. By the time the third child came along, I knew that if I didn’t deliver him, nobody would. True to form, she niggled along for a long time, then had a few contractions, and there he was. I caught my son in the hallway on the way to the delivery suite. Looking after your own family was unethical and I would be censured today. But it was the only practical thing to do and I got away with it.
Surgical assisting. I also became the main surgical assistant. Over the years, I muscled my way into doing simple procedures like appendectomies. I still think, after almost 20 years of not doing one, I could still do a routine appendectomy.
Therapeutic abortions. Almost immediately after starting a practice, I started doing therapeutic abortions. As a procedure nobody else liked to do, I fairly rapidly cornered the abortion practice for all the West Kootenay, an isolated area with slightly over 80,000 people. The gynecologists stopped doing them.
I spent a few weeks in Vancouver improving my technique including a week of late abortions. These must be the most horrific of procedures. The technique had been developed by Dr. Gary Romalis in Vancouver (he was shot once and stabbed in the back once by pro-life fanatics). Laminaria was inserted in the days before to soften the cervix. The baby was then extracted using special grasping forceps. Heads and spines came out in one piece. I found them not very pleasant. But I ended up being the only physician outside the lower Mainland doing abortions in the 12-15 week range. With laminaria, abortions could still be done for up to 15 weeks using suction. Laminaria was an absolute necessity to control bleeding.
This had the unintended result of being picketed by pro-lifers every day for the almost 30 years I practiced. One religious zealot carried a piece of plywood in the shape of a coffin in front of our clinic and never missed a day. Our only communication in all that time was a VHS video he sent me once. If I had to choose an adversary, Herman would be my choice. He had little credibility and was always peaceful. British Columbia had fortunately introduced the “Bubble Law” that kept him across the street.
When abortion doctors were being shot all over North America, I did feel vulnerable. After my divorce, I lived in the countryside for several years. Sitting and eating in front of a bay window surrounded by forest was not reassuring. One pro-lifer once wrote a letter to the editor of the Nelson News that he thought shooting abortion providers was justified. I could relate – when you believe strongly in something but can do nothing legitimate about it, it seemed reasonable to shoot someone “killing” babies.
Canada has easily the best abortion law in the world – none. After court challenges by my hero, Dr. Henry Morgenthaler, the law was thrown out and never replaced. That left me as a provider in total control. I refused no one and even did them as young as 13 without parental consent. I always encouraged underage women to involve their parents, but sometimes that was not possible. As long as I thought she could give proper informed consent, age was not an obstacle.
I thought of myself as a simple technician doing a procedure that every woman should have easy access to. Unwanted children tend to not do well in our society. Almost every patient was referred and counseling was not my job. I never turned anyone down, was not judgemental, and tried to be as supportive as possible. I saw women from all over, the day before the booked procedure, inserted laminaria if possible and all were able to return home the next day. I rarely had a complication.
About six years before I retired, the only doctor doing abortions in East Kootenay (at least a 3-hour drive away) retired – I was then the only provider in all of southeast British Columbia.
Laparoscopy. I made sure all having an abortion left with contraception of some kind. I had learned how to use a laparoscope and probably a third also had a tubal ligation at the same time as the abortion. It was a one-stop shop.
Caesarian Sections. To have an active obstetric practice in your hospital, you must be able to provide caesarian sections 24/7. When one of my partners who did sections retired, I went down to the lower Mainland, did Caesarians for a week, and started doing them too. This was even more rewarding than natural vaginal deliveries and I found them great fun. I had pretty good surgical hands.
The urologist in the nearby referral hospital routinely asked me to assist with difficult procedures like nephrectomies.
Dermatology. One day, a man, who was to become my best friend walked into my office with a very unusual rash. Dermatology is not a strength of many family doctors. I biopsied it and referred him to a dermatologist in Vancouver, over 600 kilometres away. From my history, he didn’t have to see the pathology and knew the diagnosis immediately. I thought that was pretty cool and over the next few years, took several courses in dermatology including one month at the University of Arizona in Tucson where my oldest brother was working. I read voraciously and slowly required a large referral dermatology practice (about 40% of my practice). I have great visual skills – generally taking a history was not of much value in dermatology and it often only took a five-second look to know what was going on. This became my real passion. I subscribed to several dermatology journals and devoured them. I think I was pretty competent.
Working in the Canadian Arctic.
I wrote the medical director of the Northwest Territories wanting to do dermatology there. They were keen to have specialists with GP skills and I was hired twice there, eventually visiting every town in the territory. Most were fly-in only and I must have flown in every small plane available including the greatest of them all, the de Haviland Twin Otter.
I then canvassed the territory of Nunavut in the eastern Arctic to do the same job and was hired three times, again for one-month periods. Having survived successfully for 2000 years in a harsh environment, the Inuit of Canada are an amazing people and it is sad what is happening to their culture when they move into a town.
I soon realized that I needed to spend some money in the communities and started an amazing Inuit art collection. I announced my intent on arrival in every town and had a constant stream of artists at my hotel door. My last trip was one month after I retired from my general practice. This was one of the most fulfilling cultural experiences of my life.
Outpatient surgery. With my skin practice came a lot of dermatologic surgery including a lot of nail surgery. I was already doing virtually anything that didn’t require a skin graft. I would remove anything. I was diligent with my technique and produced great scars. In retrospect, I should have specialized in either dermatology or plastics.
Like many of my partners, I did vasectomies and anything anal – hemorrhoidectomies, fistulas, and anal fissures – virtually anything that needed a knife. “Read one, do one” was my motto. When our malpractice association refused to support doctors doing circumcisions, I was left as the only doctor doing them too. People came from all over, I saw them in the ER for the first time the day of the procedure and everyone left happy.
I arrived at the ER at 8 every morning with a full slate of outpatient procedures and still always made it to the office by 10.
Methadone. In 2000, the West Kootenay was left without a methadone prescriber. I took the necessary courses and soon had over 70 ex-heroin addicts in my practice. I liked the crazy people who were now coming through my door. Methadone has its issues but is a mainstay of dealing with narcotic addicts. Everybody was weaned slowly and at least half became drug-free. They were sometimes handy patients to have. Once I was robbed with over $6,000 of camera equipment stolen. I phoned up one of my patients and knew who the thief was and who he had fenced all my stuff to by the next morning.
With methadone, I learned a lot about addiction medicine. I don’t think I was ever conned by drug-seeking patients again.
Other medical interests.
Diabetes. I was the director of the diabetes program in our hospital for all 30 years I practiced.
Hemophilia and AIDs. I had two unrelated teenage hemophiliacs. One day in 1984, I received a notice to stop using cryoprecipitate, then the main therapy for hemophilia, but unfortunately, one derived from pooled plasma mass produced in the US. Both died terrible deaths within a few years. I then became the local AIDs expert.
RN program. I was the medical advisor to the local RN nursing program for many years and yearly gave a lecture on neurological exams. I used the pneumonic for the 12 cranial nerves “Oh, oh, oh, to touch and feel a girl’s vagina and hymen”, something I will never forget.
By the time I permanently retired from my medical practice at age 53, I had developed the most amazing practice, one that I doubt could ever be possible today or in any other town. It was unbelievably rewarding – and perfectly suited to my Asperger’s mind. I looked forward to going to work every day. But by 2006, I was ready for something else, permanently gave up my medical license, and never thought of medicine again.
I did apply to MSF, wanting to work in their worst missions. Without a medical license, I would only be able to do jobs like logistics. I couldn’t speak French so was never hired.