When I switched clinics in 2005, rather traumatically, I was temporary at first. The staff was a bit worried about working with me. I talked to the office manager alone and told her my version of the story. I was working part time.

After a year I was notified that I had to comply with full time. Instead of 9 to 4, I had to do 8 to 5. They notified me of this with a note on my desk. I wandered up to the office manager. "No." I said, "We have a contract. I will be happy to meet with them to review the contract."

I met with the COO and CEO. I could never ever get a question answered by messages on phone or by email. Apparently email is too quick response and administrators might be held to their word in writing, so they never responded to any question except in person. This was highly inconvenient, but whatever.

I went to the meeting. "I understand that you want me to extend my hours to 8 to 5." I said. "Yes," said the COO, "all of the physicians have to have the same schedule to use the space and clinic staff most efficiently." "Well, I am just reluctant to extend my hours when I'm temporary."

"Temporary?" said the CEO, looking confused. "Yes," I said dolefully. "You said a year ago that I was temporary in this clinic." The COO remembered the previous meeting, though. She said, "You're permanent. You know that." I grinned. "Oh, good, I'm delighted to hear that. Of course I will be willing to extend my hours." I stood up and held out my hand and shook theirs. "A celebration is in order! We do have to revise the contract though, correct?" The COO rolled her eyes. "Yes." I admit, I might have been irritating occasionally. However, I don't hold with changing a contract by putting a note on someone's desk.

I was happy in the clinic. I felt at home and I felt liked and I was happier than in the previous clinic. And the symptom of happiness was what I did with my keys. My house key and the clinic key were the same shape and color. And suddenly I couldn't keep them straight. I would try to open the clinic with my house key and my house with the clinic key. When the door wouldn't open I would take the key out and look at it. And it would take a moment before I would think, "Oh, that's the clinic key. This is my house." I was happy in both places and so my brain could not tell them apart. I felt safe in both places and I wanted to be in both.

That fell apart under the pressure from the administration to be "productive". We, the physicians and midlevels, needed to "produce". Patients as widgets, as shirts to sew. See people for one thing only and make them come back for anything else, use templates to shorten the visit and make it "efficient", ask questions like a robot, 20 minute limit (and some clinics have 10!), call and being up in the night does not count as hours, the hospitalists are paid 10 times as much for their call as ours, and finally a daily quota of patients to see. The 92 year old with 6 chronic disorders who walks slowly down the hall with her walker is to be rushed through and I can only talk about her blood pressure today. Insane, and against everything that I chose Family Practice as a specialty: I wanted to care for the whole patient.

I stopped mixing up the keys.

I've spent a bunch of time in the last 2 weeks on the phone about a woman in her 80s. Trying to coordinate three specialists. I called her yesterday again and we revised the plan. "Lawyers charge for the time on the phone," she said. "You are spending all this time on me." I laughed. "Medicare won't let me and I can't really charge for phone time." Well, actually one can, but you have to document every minute and it has to be over some stupid number of minutes per month and frankly it would take more time to try to extract the money from medicare than it is worth. The little secret that insurance companies have recognized is that doctors like doing medicine more than paperwork or billing, so many don't bill for half of what they do. "You should set a monthly fee, like that other clinic I went to," she states. "We can talk about that," I say. No, I don't want to do concierge care. I want to be able to see anyone who walks through my door: single payer and health care for all. There are some I can help and some that I can't, but at the very least I can listen to the person's story.

I have my own clinic. The clinic key is silver and the house key is gold. But I am mixing them up again.

Happy, happy.

I was in Reno for four days, and when I wasn't with my friends, I hated it. I hated the rain and snow that bombarded the city, hated the dying hulks of casinos stripped bare of slot machines, left to die in the waning flashing of their lights. I hated the ever-present stench, the thin air, the dryness that required twice a day moisturizing. I hated the view out of my window, and the sweep of the Sierras with snow shrouding the very top of the range.

What did I do? I paced. I grumbled to all and sundry. I got very little done, save for laundry and some sparse writing. I formulated a quiet, tired hatred of the city of Reno, and ordered copious amounts of coffee through room service. I brooded in my in-room jacuzzi, I brooded over the laptop, and I brooded all the way through the garishly decorated casinos.

So, a little bit about the room at the Peppermill.

In 2010, the economic downturn was significantly worse than it is right now. Reno wasn't seeing much traffic. Hotels were dirt goddamn cheap, which is how I ended up with this palatial jacuzzi-having suite.

The room was laden with gold-encrusted, gold-painted, and gold-trimmed furniture. Style of the day was ornate, baroque, and distinctly overstuffed. The walls were thick enough that I only heard my neighbors once or twice.

The bathroom was absolutely coated with marble, and separated out into three rooms - one dedicated room for the toilet, one huge, glass-walled shower, larger than some bedrooms I've had, and the main room, with a three sink, gold-edged, pink marble vanity and a mirror stretching the length of the entire room. It was in this room that I spent a fair amount of time, drinking wine or coffee in the jacuzzi and watching bad cable TV.

It was a weird kind of luxury, but at least the wine was cheap.

Reno is dying. Reno is an aging town that exists to prey on the grandmas who, at 3AM, can still be found pulling the arms of slot machines with glazed eyes and practiced, nigh-mechanical precision that falls into sync as they congregate. The restaurants are full of bloated vacationers and befuddled, disappointed tourists: the streets are filled with empty storefronts and bums.

On the last day, the rain stopped. The wind picked up, and the power lines swung back and forth. I visited my friends for the last time in their apartment. Twenty minutes in, power cut out abruptly to their building, victim of the high winds. We sat in the dark by the light of my LED flashlight, making shadow puppets and joking about the terrible cell reception to be found in the city.

I left my friends around midnight, planning to get an early start over Donner Pass. As I left, I passed a utility truck on its way to the apartments. Five minutes after I got to my hotel, the power came back on for my friends.

I packed my things, I set my alarm for 5AM.

I got up… at 8AM. I mean, come on, it was my vacation - and by the time I got up the pass, it turned out this was wise. It was still chain control over the summit.

It was time to go.

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