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The last time I worked in Virginia was already over 2 years ago. When they had initially told me they needed help back in December, I was looking forward to going back. It’s always nice to catch up with old friends and co-workers there.

Also, I have since read a book about Thomas Jefferson and would like to visit his estate in Charlottesville, VA, as corny as that sounds.

However, now that I have recently worked in a regular family practice in San Diego, I was a bit reluctant to return to the Virginia job. Virginia is the first place I had worked for this geriatric outpatient practice I have worked with on and off over the past 5 years.

Going back there meant going back to working with a complex and sick elderly population. Being completely responsible for their hospitalizations and ER visits. And having to manage their 30+ plus disorders without placing many specialty referrals as was the model of the company.

On the other hand, I was looking forward to creating relationships with patients again. Seeing relatively young and healthy patients in family practice clinics doesn’t allow for forming much of a relationship. This is because they come just once a year for a physical or if they need something. Versus elderly patients come to our clinic every month or even more often if necessary.

When I had the call with the medical director prior to me returning to Virginia, she said “everyone is so excited to have you back!” So, I knew I had to move forward with the assignment. The medical director there is new but I have heard good things about her. I am hoping my time there is flawless. As noted in my previous blog posts, there tends to be some type of drama when I work at these geriatric clinics. At least it will be spring time there, so can enjoy the outdoors.

I am writing this towards the end of my assignment in San Diego. I’ve had a really good experience. San Diego itself is still a majestic place. The work side has been pretty straightforward and “easy” considering the complex geriatric patients I typically work with.  

The other PCPs here told me how impressed they are with me. That I surprisingly just jumped into the new role and rarely have any questions for them. They said typically new providers have tons of questions. I reassured them that it was likely because I already worked here before, albeit 5 years ago.

Some of the physicians are within a year out of residency, so they come to me with medical questions or to see if I agree with their plan of care. This has been quite flattering.

I have enjoyed getting experience in things I don’t see often in geriatrics such as sexually transmitted diseases, identifying developmental delays in children, and reassuring young adults that their abdominal pain of 3 months is not appendicitis.

Interestingly in California I noticed a lot of patients try to get short-term disability through their PCP for medical reasons. It must be a California thing because I am filling out disability forms on a weekly basis. This is in contrast to working in other states. Some reasons for short term disability include status post stroke, fracture, or cancer. I believe the state provides them with financial benefits.

It’s gotten to the point though that no one wants to work. For instance, I had a patient with diabetes ask for short term disability. He said it’s because sometimes he doesn’t take his insulin properly and his sugar drops. I told him there are millions of people with diabetes in the country, so if every one of them was on disability we wouldn’t have a work force. And of course, he needs to start taking his insulin properly.

One of the other PCPs told me she had a patient request short term disability for a low back cyst they had removed over a year ago… The short-term disability request has become the new narcotic refill request. Where patients start crying and put on a show if you decline authorizing them for short term disability.

I had a patient that I gave one week off for abdominal pain, who showed up one month later saying her job fired her because she never went back to work, and now I had to fill out HR paperwork stating she was out for medical reasons. I told her I felt like I was being taken advantage of because I only gave her 1 week off, and if she was in so much abdominal pain as she claimed, she would have completed the imaging and lab tests I had ordered by now. So, she started crying and saying she was so depressed etc. which of course she never mentioned previously. That’s probably been the only part of my job I haven’t enjoyed.

I usually see 20-22 patients per day, a mixture of them being phone visits. I often finish early and in between patients, I even read a book which I am able to finish in about one week.

They asked me to extend here for another 3 months. That would have been great except I already committed to working in Virginia in the spring. I wouldn’t want to back out of the Virginia job because I’ve had a good relationship with that company for the past 5 years. However, I wouldn’t mind returning to this specific clinic if the need arises again in the future. 

On my last day, the clinic staff spoiled me with breakfast – bagels and donuts for everyone. My medical assistants gave me some going away gifts. And my fellow Doctors and Nurse Practitioners treated me out for lunch. I thought that was so sweet and started to feel a bit sad about leaving. It’s amazing how you can develop relationships with people in such a short time. They are crossing their fingers that I come back!

I had a patient that came in the other day for a routine follow up. She hadn’t been to the clinic in about 6 months. She had over 20 diagnoses in her medical record. One of them being Diabetes Mellitus type 2. She was overdue for blood work, her diabetic foot exam and annual eye exam. She also told me her insurance was no longer covering byetta, so needed a different medication prescribed.

She then told me she needed medication refills, some were not even on her medication list. She also needed a referral to orthopedic to get a hip injection. She was also feeling depressed and wanted to try a new medication. She was interested in getting therapy so I placed a referral to our mental health department as well.

She said she called her insurance and they told her acupuncture was covered so would like a referral to them for her multiple joint pain.

At the end of the visit, she said she forgot to mention she also needed a referral to neurology for her headaches. She wanted to try botox.

I told her I had already placed orders for her labs, did a thorough physical exam, placed referrals for her eye exam, orthopedic, mental health, and acupuncture; in addition to refilling her medications, changing byetta, and trying something new for depression.

I thought it would be best to hold off on the neurology referral until a later date. She seemed disappointed but I told her that perhaps her headaches were due to her depression and may improve with medication for mood disorder, and that acupuncture may help with her headaches as well.

It got me thinking about the fact that primary care providers always wish they had more time with their patients. 15-20 minute visits is often not enough to treat a complex patient. After I was done with this specific visit, I asked the other providers if they would have preferred to have an hour with this patient to cover all bases, or just to have her come back more frequently such as monthly (she doesn’t have to pay a copay).

Interestingly, they all said they would prefer the longer 1 hour visit. I used to have that same perspective, but after working at the geriatric clinic for several years, I have realized that frequent visits are more effective in providing good patient outcomes.

For instance, it’s not ideal to have a patient try more than one new medication at a visit. This is because if they have side effects, you wouldn’t know exactly which medication was causing it. Additionally, such as in the above visit, when patients request multiple referrals, it can become overwhelming. Most of the time, when a patient has more than one referral, they are unlikely to go to all the specialist visits without you reminding them at a later visit.

In one visit with a complex patient, I can easily adjust their blood pressure medication, review their lab results, refer them to nephrology, order compression stockings for their leg swelling, and encourage them to quit smoking. After the visit, the patient often forgets the summary of the visit, no matter how many times you repeat it to them. Thus, they will forget to pick up their new blood pressure medication from the pharmacy, and are unaware they need to follow up with referrals to get their nephrology appointment scheduled or find out where they can pick up their compression stockings.

This is why I think it is best for each visit to be focused. That way you have ample amount of time to evaluate a disorder and the patient can be more proactive in their care.

Once I explained this to the other providers, they all seemed to agree that frequent targeted visits may be more effective after all.

I know patients are often looking for a quick fix, but the reality in healthcare is that the body is so intertwined that one problem can cause other problems to occur. There is no point in giving a pill for every single symptom. That is why it is important to treat one thing at a time and perhaps you won’t even need to treat the other problem at a later date. 

Would you prefer to see patients more frequently or have longer but more rare visits with them?

One of my friends asked me when my last trip abroad was. They were surprised when I said the end of 2019. I didn’t travel internationally throughout 2020 due to covid. It was the first time in over 12 years that I hadn’t traveled abroad.

I know plenty of people that still traveled to the Caribbean or Mexico even during covid restrictions. I chose not to for various reasons. Of course, I didn’t want to get covid and spread it to others. But most of all, I didn’t want to be stuck anywhere abroad.

Some countries closed their borders with a short notice and cancelled all flights. I didn’t want to be stuck in another country without any way home.

As I mentioned in a previous post, I did get covid from a patient and my symptoms were mild. But who’s to say I couldn’t get it again and have even worse symptoms the second time around. Thus, I didn’t want to have to quarantine for 10-14 days away from home.

Now that I am vaccinated and covid rates seem to be improving in the USA, I am considering traveling again. I am hoping I can plan to go somewhere internationally in late summer or early fall. I may travel somewhere close to the USA such as the Caribbean or Central America first and see how that goes, before planning to go somewhere further away.

Surprisingly I didn’t have travel withdrawals in 2020. I think it’s because I had already been to over 40 countries and still had memories there to reflect upon.

Have any of you traveling abroad since covid? I can’t wait for my next trip!

Back in September 2020 I had a patient come in to the clinic with a sore in his mouth. He obviously had to pull down his mask for me to look inside his mouth. The next day the patient decompensated and ended up in the hospital – positive for covid.

About 5 days later I developed a severe headache and extreme fatigue. I decided to get tested for covid but my results came back negative. Although I was sick, since my covid test was negative, I was still expected to work. I remember being so tired after work that I would just collapse in bed and sleep until the following morning.

I ended up being sick for 2 weeks and the last week developing no taste and no smell. Obviously these are classic covid symptoms, and I have never been sick for an entire 2 weeks in my life.

I shared this experience with my family and friends to let them know that there is such a thing as getting a false negative when it comes to covid testing. So even if they have a false negative test but were exposed to someone with covid, they should continue to quarantine. Unfortunately, as an essential worker I didn’t have that luxury. My clinic and I are lucky that I didn’t infect anyone else.

This experience infuriated me a bit. I was frustrated that I was doing my part in social distancing, but my patients weren’t. Some of those patients told me how they would still go to restaurants, even though they were 70 years old or older. And as a result they were putting me and others at risk.

I was also frustrated that even though I was sick I still had to work. Of course, the timing of me getting sick was inconvenient. Three out of the four other PCPs were already out for FMLA or PTO reasons.

On the bright side, I had such a mild symptoms and no breathing issues. I am grateful I was able to recover and that I didn’t infect anyone else. I am also grateful that I was able to get the covid vaccine during my second day of work in San Diego. My only reaction was that I had arm soreness for a few days, similar to the tetanus shot.

Have any of you gotten covid from work?

One reason I don’t like working in California much is because they have such a high rate of state income tax. With my income range, I have to pay 9.3% in state income taxes. This is especially annoying when my residential state is Florida. Depending on the state, I can often get some of those state incomes taxes back when I file my taxes.

To avoid having to pay 9.3% of my income in CA state income taxes, I have devised a plan. I decided to front load my 401k and max it out during the 3 months I will be working in California. This means I will be contributing 50% of my income to my 401k each week. I will be able to max out the 19,500 allotted contributions by the time I finish my assignment here.

So instead of having to pay $300 of taxes to the state of CA each week, I only have to pay: $70. I won’t owe more state income taxes at tax time because technically my overall taxable income while working in California is the total amount after my 401k contributions.

Obviously, this hack comes at a cost. Since I am contributing 50% of my income to my 401k, my paycheck will be significantly lower than usual. Fortunately, my costs are low and I can still afford to live off of this lower take home pay.

Have you ever tried such a hack before?

1. San Diego Zoo

I am not a big zoo person but the zoo in San Diego is one of the largest in the USA. It is definitely my favorite zoo. They even have a section with over a dozen koalas (you know most zoos only have one koala).

2. Mission Beach/ Pacific Beach

This is my favorite place to hang out in San Diego. They have a boardwalk which is fun for biking, skating, walking or running. They have a small theme park on the boardwalk as well. You can hang out at the beach, play volleyball, surf, or go kayaking on the bay. There are many restaurants to grab a bite to eat.

3. Sunset Cliffs

Beautiful site to watch the sunset or even to participate in yoga classes in the morning. Plenty of people have picnics here.

4. La Jolla

La Jolla Cove is an underwater marine park. La Jolla Shores Park is where you can visit to see a large amount of seals sunbathing at any given time.

5. Gaslamp District

Great area downtown for night life. They have tons of bars and restaurants. They often have festivals there too and hidden piano bars.

6. Seaport Village

Check out the famous kissing statue (the unconditional surrender) and the USS Midway Museum. You can even rent an individual speed vote to tour the area.

7. Balboa Park

Beautiful park with lots of gardens, Spanish architecture, and bike/walking paths.

8. Coronado Island

Gorgeous views of the city and has its own beach which is less crowded than MB/PB. Famous for its Coronado Bridge which is a lot of fun driving on when you have a convertible!

9. Torrey Pines

State Natural Reserve for hiking, bird watching, looking at wild life, and exotic plants. They have their own beach too.

10. Old Town

This is the first European settlement in California. Now it’s more of a tourist sport for adobe homes and Mexican restaurants.

Since the clinic I am working at is in a different location than where I was working previously, I decided to live in a different area. Last time I lived in Mission Beach. 

This time I decided to live in Ocean Beach/Point Loma area. This area is different from Mission Beach because it is less of a party scene and more laid back and hilly. It’s a 20 minute commute to work. I could have chosen to live closer to work but I always prefer to live near water when possible. Plus 20 minutes without traffic isn’t bad. I love being able to walk to the sunset cliffs on weekends.

I ended up getting a furnished 2 bedroom apartment. This is a great feature because I have an extra bedroom for visiting guests. Most importantly I have a heater, which is nice for those cold nights.  

Below are some pictures of my new place! 

San Diego is even better than I remembered! The weather is perfect. All of the different scenery is beautiful. It is so diverse. And there are sooo many young people here! I guess I had been in Florida for too long haha.

I was given a 3-day orientation and EHR training since I haven’t worked here in 5 years. The EHR is the same which is pretty straightforward. I was given one afternoon to shadow another provider. I am pretty sure I had a couple of days shadowing last time, but maybe it is reduced due to covid. It’s not a big deal to me, but there was a locums physician that was doing orientation with me. She seemed to need more shadowing than that, especially since she hasn’t worked here before.

I was given a ramp up schedule, which is a mixture of office visits and phone visits. I like this particular clinic a lot, more than my main one last time. My patients are mostly Spanish speaking which is nice. They have been very pleasant so far. The medical assistants at my clinic are really helpful and friendly. The PCPs are as well. The last patient of the morning is scheduled 1 hour before lunch and the last patient of the day is scheduled 1 hour before the end of the day.

This is great because if you are running behind you have that extra time to catch up and finish notes. The no-show rate is pretty high, but there is often a walk-in waiting to be seen during a slot where you have a no show. This is fine since it is usually for a direct reason or something quick like medication refills. I also like that patients are required to check in 15 minutes before their actual appointment. So no late patients are accepted.

I was a bit nervous about seeing pediatric patients again, but the EHR made it easy by having guiding well child exam templates and immunization records. It’s actually been pretty fun working with that population again.

The community health centers have so many resources for their patients which is excellent. They have a transgendered clinic, mental health center, registered dieticians available, and HIV services. There is a lot of social support for the patients.

The most challenging thing for me has been deciphering between normal cold symptoms and covid19. We always encourage patients to get tested, but sometimes their covid test is negative – and they continue to have symptoms. So you have to decide if it is a false negative for covid or if you should treat them for other disorders. Also, since California is the hot spot for covid right now, we try to deter patients with covid like symptoms from coming to the clinic at all. This can be challenging when a patient has a history of asthma and you would love to be able to listen to their lungs but administration wants us to encourage them to utilize the ER if they do not get better.

Fortunately, I was able to get my first covid vaccine on my second day here. That was fast. Had I waited to get it at home in Florida, it would have probably taken forever. My only reaction was arm pain that lasted a few days.

I am really loving my time here and wish I could stay forever! Too bad I am a nomad and it is too far from my family in Miami. They are still getting adjusted to the time difference and continue to call me at 5 am or while I am at work. It’s too early for me to decide if I want to extend. You get a better feel for a place after working there for 1 month.

San Diego is probably my favorite city in the USA. I absolutely love it here. I worked here about 5 years ago and have always wanted to return. When I worked here before, I worked at a community health center between 3 different clinics. I liked working at 2 out of the 3 clinics. However, the clinic I hated was my main one (where I was at most days of the week). I didn’t like the leadership there and was always overwhelmed with the quantity of patients.

The opportunity for me to return to work with the same community health center was ideal this time. This is because I would be able to only work at one clinic, instead of floating around. I prefer this because when the clinics are large, it’s difficult to remember everyone’s names and where everything is when you are working there for just 3 months. It’s easier to get overwhelmed when you are not comfortable.

The usual patient per day volume is 20 patients per day per provider. I prefer to see closer to 16 patients per day. Due to covid, they converted some of their scheduled patients to phone visits. The phone visits are quick so this made me more comfortable with accepting to see 20 patients per day.

Before accepting the San Diego position, I was also asked to help out at my previous job in Virginia. They wanted me to start in January as well. I ultimately decided to move forward with the San Diego position for 2 main reasons. I needed to work at a family health center to gain more experience working in pediatrics. I had been working with only adults for the last 18 months. If I didn’t work with children soon, I would eventually lose both my skills and credentialing to be able to work with all ages.

The second reason is that it is obviously too cold for me in Virginia from January-March. I did work there during that time frame once, and it even snowed. Fortunately, they understood that I needed to gain some pediatric experience, and asked me if I could help out once I am done in April. I told them I would let them know once I started my new job in January.

I would love to go back to Virginia because I have a lot of friends there and it’s a quick plane ride from home. But I wanted to see what it was like to work with all ages again. Would I love it so much that I would want to continue working with pediatrics again? Would it be way easier than working with my usual complex geriatric population?

I was a bit nervous to start the job in San Diego because of my previous challenges. I am not a fan of the limited scope of medical assistants here. Such as not being able to swab for strep or flu. Yet, it has been 5 years since I worked here. Since then I have worked at 15 other places, including years of challenging geriatric work. I was curious to see if the job would be “simple” to me compared to other places I have worked.