Home Forums Discussions General Discussion Saipan practice

Some of you asked that I check back in, and tell you a bit about medicine here in the Northern Marianas. These are, of course, early impressions and a work in progress.

The hospital has about 75 beds. The internal medicine service currently has 6 physicians working at any given time, as one is off on vacation at any given moment. We are all general internists. One of the joys of working here is the ability to resurrect all those skills that had atrophied as Alaska became more sophisticated. Need a temporary pacemaker? Sure, I've done that. Central lines? Yep. Septic shock? Drag out the "surviving sepsis" checklist and quick open the Sanford guide and Washington Manual on my iPad mini. We do not have any instant medivac/lifeguard service. Off island transfers are decide once a week, and go with an escort on a commercial airliner. Everyone keeps a passport up to date, as the escort duties fall to the person who is not on duty that day. Mostly they go to Guam or Manilla, rarely Hawaii. The decision also involves insurance. The island population is a mix of many cultures and nationalities. Native Chamorran, Carolinian, Chinese, Bangladeshi, Philippino, Micronesian, etc. Some are US citizens, like Saipanese, but a patient from Chuuck, or Palau is not, and so not eligible for Medicare or Medicaid. I have a map of the South Pacific on my wall and periodically study it to try and keep the geography and political boundaries straight, as a patient might say they are from Yap, and I'm not sure if that is Marianas (US) Or Carolines (not covered). Private insurance is rare.

There is one formulary on the island. It is somewhat limiting, but saves having to chase the latest and greatest and constantly learn doses of some medication a consultant is enamored with after a visit from the detail person. Also, I only have to learn ONE formulary.

There is an AWFUL lot of diabetes, with attendant complications. I was amazed at the size of the dialysis unit here.

The hospital is in the early days of the EHR. They are using RPMS, which they got from the Indian Health Service/VA. I expected a terrible lash up, but have to say it is really quite good. Advantages over AC : It is blazingly fast (no waiting for imported items to open, the open instantly). It is rock stable. Our group is slowly building order sets and templates, but the templates are going to be very limited. No multi page notes serving only to impress an ignorant auditor are contemplated. Having multiple windows open is possible. Disadvantages: The PMH, SH, FH are not brought forward into each note. That is solved by cutting and pasting. No integrated prescription writing, so discharge meds are hand written.

Currently, the EHR is not used in the outpatient clinics or ER, so a review of the paper chart is necessary. We are trying to summarize the chart when a patient is admitted so it can be referenced at a later date.

Radiology is read by telemedicine from Guam. This can be frustrating, as midnight stat readings are not available. Because of licensure and reimbursement issues finding a more responsive group does not seem to be possible.

The hospital can do a reasonable number of basic stat tests, but can't do things like stat lactate levels, for example. Send outs take several days to get back. In hospital microbiology is new, and has some bugs to get worked out (in a manner of speaking).

The term "meaningful use" was brought up once during my EHR training session, I think somewhere in a sentence that included "... if we were going to do that..."

In terms of surroundings, it is a stunningly beautiful island... every fantasy of a South Pacific island you have ever had is true. We have been warmly received, As Caucasians we are clearly a minority (except our daughter who is Chinese by birth), and now I "get it" when an African American friend says he NEVER forgets that he is black. I am having to adjust to learning new accents and dialects (there are several), a difficulty compounded by noise induced hearing loss. Our daughter, on the other hand, fit right in, and is off exploring every hidden beach and adventure spot with her new friends.

Back in Fairbanks, it is snowing, and the low temperatures are approaching zero. Right now it is 82 degrees, and there is a typhoon warning for later tonight. Les bon temps roulez!

David, you are truly adventurous. Glad that you enjoy the challenge. Sounds like they need you.

Thanks for keeping in touch. Sounds like you're having a blast though I did perhaps detect a faint wistful longing to feel the crunch of snow underfoot.

I think it was real faint, give it a year and it might not be.

It's surprising how quickly it does become faint, Wendell. The issues of closing the practice and moving were really horrific. I really started to feel compassion for people with generalized anxiety disorder. I'd have fits of trembling, and actually wondered if I were having thyroid issues. Once on the plane, it just fell away. Half way to Hawaii, I was feeling normal. By the time I got here, Alaska was starting to get filed in the memory part of my brain. It is still home, in the sense that "when you gotta go there, they gotta take you in", but now I am also comfortable calling this home.

I guess the reason I say that, is that there is always a great reluctance to make a radical change in one's life. I worked in the same place for 40 years, so I don't feel I am a vagabond at heart. There are many stories here of colleagues who seem riven by the stress and problems of their practices, and certainly national physician satisfaction polls are in the toilet. Throwing my practice and life to the wind was not an easy task, and I had absolutely no reason to leave the comfort of what I was doing. But, the pain and loss (and it was very real) vanish amazingly quickly, and the excitement of a new adventure has rewards beyond measure. We all deserve better than lives of quiet desperation.

Great to hear from you David. Please keep the updates coming!

It's really good to hear back from you David! I'm glad you are enjoying yourself, and followed your heart!

David, I thought you were a pioneer Yukon man working in Alaska. Now I picture you in an outrigger canoe! A bold change. I truly hope it works for you!

Tom