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Thursday, February 21, 2013

How to perform a fecal transplant--why make this so very difficult?

Fecal transplant, thanks to the recent article in the New England Journal of Medicine out of the Netherlands, has made it to the front page, the big time. In my inbox today was a link to a how-to article from medscape from a doctor from Eastern Virginia Medical School who apparently does the occasional fecal transplant for recurrent Clostridium difficile colitis.

In this article, the author says that one must do $500 worth of testing on the donor, then make up a particle free stool slurry of stool and non-bacteriostatic saline under a hood (due to the biohazard aspects of making poop soup) filter it and instill the mixture via a colonoscope to the patient who has taken 3 gallons of polyethylene glycol solution and preferably had only clear liquids for 2 days. He says that the procedure should only be done for patients who have had Clostridium difficile for 3 months which has not responded to antibiotic therapy.

There is no evidence to suggest that giving donor feces by colonoscopy is any better than giving it by low volume enema, at home, or by nasogastric tube. Colonoscopy carries significant risks: anesthesia is risky and colonoscopes can cause perforation and bleeding. Colonoscopies are expensive. The recent article in the New England Journal used a naso-duodenal tube, not a colonoscope.

There is reasonable evidence that fecal transplant is effective for treatment of ulcerative colitis, an autoimmune disease of the colon that causes chronic disability, colon cancer and internal bleeding. Acute Clostridium difficile claims many lives, and there is abundant experience of treating it with fecal transplant. Limiting this therapy to chronic cases seems a bit excessively restrictive.

The author of the medscape article notes that some of the patients in the recent trial of fecal microbiota transplantation developed new diseases, some of them autoimmune, which might have been related to the transplants. It seems unlikely, but I would also wonder whether some of the patients found that more problems than just their Clostridium difficile were resolved. Much is still not known and will only be revealed as more research is done with larger groups of patients.

As far as the $500 of tests that need to be done on the donor, I wonder if perhaps some of these could be eliminated. Clearly the donor should be checked for body fluid transmitted diseases such as HIV and hepatitis, though a family donor of known low risk (a child, for instance) might safely be presumed to be uninfected. Extensive stool testing for bacteria and parasites in a donor with no intestinal difficulties might also be unnecessary, especially if that person's history was well known.

As far as the actual logistics of delivering donor stool to recipient colon, I suspect nothing more than a commercially available enema bag and tubing would be necessary. The soup to be delivered could probably be easily and cleanly mixed up in a ziplock bag, with no need for a blender. As far as preparation with a clear liquid diet and gallons of polyethylene glycol, I am curious to see evidence that supports this (I don't think there is any, yet). Cleaning out the bad bugs seems like a good approach, but patients get very weak after a standard colonoscopy prep so a prep that includes days of fasting plus more polyethylene glycol might lead to its own problems.

I am starting to think about the nuts and bolts of all of this because, as a hospital physician, I will soon be faced with a patient for whom fecal transplant will be an obvious life saving intervention, and I will have to figure out how to do it with as little fuss as possible. It will be unethical for me to allow someone to die when antibiotics fail, as they so often do, when evidence shows that a fecal enema would probably be curative.

Monday, February 18, 2013

Bacteriophage therapy, biome reconstitution, heparin--potential scientific breakthroughs plagued by un-coolness

During the last year I have been paying particular attention to lesser known and under appreciated miracles in medicine. It is a mystery why miracles of any sort would be under appreciated, but it is so very human to ignore things in plain sight which disrupt our deeply held belief systems or even are simply not what we are looking for.

For those readers who don't believe that they could actually ignore something that is both true and in plain sight, I refer to this YouTube video, a classic experiment in selective attention. If that is not enough, there is a study in the journal Psychological Science (just reported in the popular press yesterday) which shows that radiologists looking for cancer failed to see a very obvious and ridiculous image on a chest x-ray.

I would propose, also, that we are even more likely to ignore information if that information is uncool. Things that are cool make us feel indestructible and things that are uncool make us feel weak or embarrassed or out of place. Olympic snow boarders, action movie heroes and dancing flawlessly in high heels are cool. Sexually transmitted diseases, urinary incontinence and broccoli between the teeth are uncool. In medicine, heart transplants, miracle drugs and prosthetic joints are cool. Here are a few things that we really do not hear much about at all, despite the fact that they are inspiring, potentially paradigm changing and have been around for years.

Bacteriophage Therapy:
Researchers have been aware of tiny viruses which kill bacteria since the late 1800's. Early on it was not clear that these elements were alive, and it was not proven until decades later that they were, in fact, viruses. In any environment where bacteria naturally grow, bacteriophage live as well, and they can be separated from the bacteria experimentally by using a fine porcelain filter. The water we drink contains phages, since purification is not designed to remove them and they are innocuous. When phages are deliberately grown with bacteria, we can isolate them in concentrations that can be used to treat bacterial infections. In the 1940's, before antibiotics were commercially available, phages were produced in the US by the Eli Lilly company. As early as  1919 phages were used to treat children with severe dysentery, and in the 1920's thousands of people with cholera were treated with it. When antibiotics became more widely available, phage therapy dwindled in popularity. A scientific paper written in 1934 questioning its utility was another nail in the coffin. Reviewing this paper in the light of what is known now, it is clear that its negative conclusions were heavily based on weak science. Phage research and therapy has continued to be actively pursued in Poland and the Republic of Georgia, but the kind of science we like in the US, the double blind placebo controlled trials, have not been done. There are papers comparing antibiotics to phages, which are compelling and generally show phages to be significantly more effective. Phages have been given orally, topically, intravenously, in the eye, intraperitoneally, in large doses, to humans and to laboratory animals with essentially no toxicity. Producing phages is easy, since they can be isolated from a bacterial broth with a filter which is not much different from what we backpackers use to pump safe water from mountain streams. When bacteria become resistant to a phage it is simple to create another phage that is effective for that bacteria. Phages and bacteria evolve constantly in nature in just that way.

It is clear that now that broad spectrum antibiotics are losing the war against resistant bacteria and that their overuse is creating huge problems for us, not to mention their expense and myriad side effects, we need to look seriously at using bacteriophages therapeutically. The US is not, however, geared up to do this at all. Drug companies are not interested, since they don't have the equipment and, since phages are living organisms, they can't get exclusive rights to market them. Universities and research institutions could take up the ball, and there are bacteriophage projects ongoing, but they are hardly able to bring this to full production capability. It is at least theoretically an advantage to use a mixture of phages to treat infection. It would be very difficult to accurately characterize a diverse population of phages which would hamper approval processes.

Also, bacteriophages are quintessentially uncool. The main research institutions which produce phages are the Eliava Institute in Georgia and the Hirszfeld Institute in Poland. Much of the research was done by the former Soviet Union. Eastern Europe is, at least to scientists, basically uncool. We don't understand their language, we don't trust their methods, we are uncomfortable with their culture. A major source of therapeutic and experimental bacteriophage isolated at the Eliava Institute is the polluted river which runs through Tbilisi, the capitol of Georgia. Sewage is uncool. Phages have been around for years and still we don't use them. Obviously they must not be effective. We worry that we might be duped into believing that something is effective when it is not, which would be very uncool. Scads of research, though not scrupulously done, strongly suggests that bacteriophage therapy works. (See link for an excellent review article.)

Biome reconstitution and fecal transplant:
I have written several times about fecal transplant, most recently after the publication in the New England Journal of Medicine of an article out of the Netherlands showing a clear superiority of instilling healthy donor stool in the intestines of patients over use of antibiotics for Clostridium Difficile colitis. Various ailments of the colon, and possibly even obesity may be caused by alterations in the flora of the lower intestines and may be effectively treated by adding an appropriate bacteriological community. The use of healthy poop to cure disease of the colon is probably ancient, and has been in our medical literature since the 1950's. Research has shown it to be staggeringly effective, working within days and resulting in long lasting effectiveness with only one treatment.

In the first decade of this millenium, good research out of Duke University suggested that losing helminths (worms) from our guts due to improved sanitation has been responsible for various diseases of autoimmunity, including allergies, inflammatory bowel disease and maybe multiple sclerosis. There is even a possible connection with autism. There is some good research showing improvements in Crohn's disease and Ulcerative Colitis by reintroducing helminths.

I would suggest that giving people worms and introducing poop soup into the intestines by way of a tube is icky and uncool, which may be why we are so very hesitant to take up this kind of therapy even though it appears to be cheap, elegant and effective. Fecal bacteria and intestinal worms are unlikely to be heavily marketed by drug companies, upon whom we have often depended for the impetus to make major therapeutic changes. These are not things which will make anybody much money, which means that researchers, physicians, hospitals and patients will have to push for them.

The very expression "fecal transplant" is at least giggle, if not gag inducing. The term "biome reconstitution" is much cooler and should probably be the term we use, so perhaps we can get past being grossed out and move forward towards helping sick people get well.

Heparin for burns and wounds:
I have written about this at least a couple of times after being introduced to the concept about a year ago. Heparin is a naturally occurring biological molecule released from mast cells at the site of vascular injury. It is isolated naturally from the livers of pigs or cows and is used to prevent clotting. It is in every hospital formulary and has been a mainstay of therapy for clotting disorders for decades. It has anti-inflammatory and healing properties as well, which are undoubtedly relevant naturally and can be useful therapeutically. One of its main proponents in its use to treat burns and skin ulcers is Dr. Michael Saliba who first did animal experiments with it for this purpose over 40 years ago. Although articles have been published on its efficacy, it has never taken hold in the US for burn treatment, despite the fact that it dramatically reduces pain and scarring. There is quite a bit of research showing that it is effective, but it is difficult to do controlled trials since the caregivers treating the patients can pretty easily tell if their patients are not having pain. I did some little experiments using it for wounds and now have it in any first aid kit because it works so much better than anything else I've used. I, however, am not in any position to do controlled trials.

Heparin will never make anyone any money, since it has been around forever and works just fine in the 1:5000 concentration vials that are easily and cheaply available at any hospitals. Its main proponents are Dr. Saliba who is a family practitioner with an interest in burns and a very cool research project as a medical student, and many burn doctors who are non-English speakers and don't publish in our most prestigious journals. Protocols for its use are at his website which is very user friendly but looks hokey and makes a person think that there is some proprietary aspect to heparin for burns and that maybe its effectiveness is overstated. Heparin for burns is probably awesome, effective and inexpensive and failed to catch on because it will not financially benefit anyone and for various reasons it suffers the stigma of uncoolness.

Over centuries, though, many uncool concepts have eventually found enough support to become commonly believed truth. Copernicus (whose birthday is today) proposed that the sun held still and the earth and planets revolved around it. His idea was so unthinkable that he delayed publishing it for years and was even hesitant to discuss it with other scholars. It took over a hundred years for heliocentrism to be commonly accepted. It took only 5 years from the time a mother of two children with acute arthritis in Lyme Connecticut contacted her health department with concerns about a possible infectious cause until an effective antibiotic was found for Lyme disease in 1980.  Dr. Robin Warren first saw helicobacter pylori in stomachs in 1979, established its role in causing stomach ulcers with his colleague Dr. Barry Marshall, was ridiculed for years and won the Nobel Prize for his work in 2005.

Researchers and clinicians will eventually legitimize good, effective treatments for terrible diseases even if those treatments are presently not adequately sexy to receive notice. The "truth will out" as they say. It is presently frustrating, though, to watch the glacially slow speed with which this is happening.




Wednesday, February 13, 2013

How to make your own ultrasound gel (which is also sterile and edible and environmentally friendly) **UPDATED--NEW RECIPE**

I have been doing lots of bedside ultrasound lately and realized how useful it would be in areas far off the beaten track like Haiti, for instance. With a bedside ultrasound (mine fits in my pocket) I could diagnose heart disease, kidney and gallbladder problems, various cancers as well as lung and intestinal diseases. Then I realized that I would have to take a whole bunch of ultrasound gel with me which would mean that I would have to check luggage, which is a real pain when traveling light to a place where luggage disappears. I heard that you can use water, or spit, in a pinch, or even lotion, though oil based coupling media apparently break down the surface of the transducer. Or, of course, you can just use ultrasound gel.

Ultrasound requires an aqueous interface between the transducer and the skin or else all you see is black. Ultrasound gel is a clear goo, looks like hair gel or aloe vera, and is made by several companies out of various combinations of propylene glycol, glycerine, perfume, dyes, phenoxyethanol or carbapol R 940 polymer along with lots of water. It is hard to find this information, but it is available in the material data safety sheets for the various companies that make it. The recipes are proprietary. Ultrasound gel is not super expensive, but it is not that easy to find in a store or in a developing country. It costs about $25 for 5 liters on Amazon, or $5 for a nice 8.7 oz squeeze bottle. It smells ever so slightly medicinal and leaves a sticky, then dry white residue as it dries.

There should really be some sort of powder that you mix up with water that makes ultrasound gel so we don't have to be shipping the water part of it, which is undoubtedly about 99% of the contents, long distances. But there isn't a powder. I have been looking. No instant ultrasound gel.

With a mixture of optimism and singularity of purpose I went to the kitchen and tried out 6 different recipes for an aqueous goo that would transmit sound waves. I thought that I could make ultrasound jam out of water and pectin, but that doesn't really work. Obviously there is something magic about fruit that makes pectin gel, maybe the acid or the sugar. Without fruit, even no-sugar pectin becomes about the consistency of spit. (I also tried spit, which does work, but has various obvious drawbacks.) I tried plain gelatin and water and got beautiful clear jello, which falls off the transducer, but kind of works, but is also messy. I tried corn starch and water, as if making extremely boring gravy. That was lovely and white, but the water wants to come out of it so it just slides off the transducer. I tried tapioca flour which I boiled with water, producing a nice clear, very mucoid gel which dries like glue on the skin and is very uncomfortable. I tried xanthan gum, a bacterial polysaccharide used to bind and thicken, boiled and cooled, and although it thickens the water it is slimy and falls off the transducer and makes a mess.

The recipe that worked (and worked great) is guar gum, salt and water. Guar gum has been used for a very long time in countries like India and Pakistan to thicken food and is now used often by people who can't eat gluten, to thicken gravies and make breads. Guar gum is the ground endosperm of the guar bean, which is very rich in a carbohydrate that avidly absorbs water. Guar beans are also eaten green and the pods are used as a vegetable ingredient after shelling out the beans. Guar gum is available in the flour section of many grocery stores and costs about $10 for a 220 gram bag. It is purported to be good for diarrhea, constipation, diabetes and lowering cholesterol. It has been added to infant tube feed formula in intensive care units to decrease stool frequency.

I messed with the recipe awhile and came up with a very nice slightly caramel tinged ultrasound gel this way:

1. Mix 2 teaspoons of guar gum with 1-2 teaspoons of salt. (The amount of salt isn't vitally important since it is just added to keep the guar gum from clumping. Using slightly less than a teaspoon of salt per 2 cups makes a gel with which is isotonic, which would be ideal for use near eyes or other mucus membranes or on open wounds).

2. Boil two cups of water.

3. Slowly sprinkle the guar gum/salt mixture into the boiling water while stirring vigorously with a fork or whisk.

4. Boil for about 1-2 minutes until thick and well mixed.

5. Cool before using. Save lives.

This is wonderful ultrasound gel (see photo above). I tried it and it works at least as well as the proprietary stuff, and probably doesn't dry out quite as fast. It wipes off easily and doesn't leave a sticky film. Even though it is not entirely transparent, there is no reduction in the quality of the ultrasound image compared with the standard clear ultrasound gel. It costs about 25 cents for a half pint, is sterile when you have finished making it and is completely non-toxic. The ingredients are available in many developing countries, not to mention the US. It is edible. It is not particularly bacteriostatic, though it could be made bacteriostatic with a little EDTA (but then it wouldn't be edible). It is probably best made and used for a couple or 3 days, then discarded if unused, though I kept some in a clean bottle at room temperature and it was stable and smelled fresh for over a week.

It is quite thick, like regular ultrasound gel, so it is a bit of a trick to get it into a squeeze bottle. A large bore funnel works, or the cooled gel can be squeezed into the bottle out of the cut end of a plastic bag. It can also be kept in a jar and used with a spoon.

This is kind of exciting. Now I will no longer be dependent on ultrasound gel manufacturers. If I was in Haiti, either I or someone at the house where I was staying could make up a batch of this the night before clinic and I would have fresh clean ultrasound gel with which I could be generous in my scans.  The water wouldn't even have to be sterile since the stuff is boiled when it is made. Let there now be ultrasound in places that Amazon.com does not reach!

Here's a YouTube video of how to do it.

**This article has been very popular and readers have left all sorts of new good ideas as comments. In order to make good ultrasound gel it is really only necessary to have some kind of a powder that, when mixed with water, creates a mostly transparent gel which clings to the ultrasound transducer. Polysaccharides are good for this, and guar gum is one of the least expensive that is available worldwide. A reader, however, just told me that he used glucomannan powder in a proportion of 1/2 teaspoon to a cup of water. I just tried it and it is EVEN BETTER THAN GUAR GUM. It, like guar gum, is a thickener and emulsifier, it is used by dieters to decrease appetite and is safe both topically and internally. It is available online and probably in health food sections of grocery stores as a dietary supplement. Glucommanan is a cell wall component of many plants, including the roots of the Konjac plant. Unlike guar gum it does not clump and can be mixed in cold water then allowed to thicken over a few minutes. If it is mixed into boiling water its texture is smoother than when it is made with cold water, and of course it is also sterile, which is very useful. It is almost completely clear, has no flavor or smell and leaves very little residue. Thank you commenter who goes by the name "addedupon"!

***Recently an article has come out in PLOS 1 looking at making gel with different kinds of flour-type substances readily available in markets in resource poor settings. They recommend using cassava flour which is actually the same thing as tapioca flour. The problem with this gel is that it is very glue-like and when I tried to wipe it and even wash it off of my skin, the remaining residue was very uncomfortable. When I have done ultrasound in Africa there is usually nothing available except maybe some flimsy toilet paper to wipe ultrasound gel off of the patient. It is certainly worth experimenting with different combinations (they also mention sorghum flour which sounds promising) but it is important to use them on yourself to see what they feel like when they are incompletely wiped off, as is the usual case.

Friday, February 8, 2013

Practicing Zen meditation and being a doctor

I just got back from a 7 day Zen meditation retreat in Northern California. I have done 3 of these in the last 10 years, about as frequently as I get my teeth cleaned, and similar in some ways. They are time consuming, not particularly cheap or comfortable and I feel much better afterwards. Zen, however, unlike preventive dentistry, is really interesting.

I started meditating about 15 years ago when the stresses of being a mother of small, often irritating children as well as a small town physician had made me into a person I didn't particularly enjoy being around. My sister had started meditating and recommended that I just count my breaths up to 10 and then start over again while sitting on the floor for 20 minutes. It sounded simple, and I figured I would do an experiment, counting breaths every morning for a month and I would see if I was a better person. It was difficult. I kept falling asleep and could rarely actually count my breaths up to 10 without becoming distracted. At the end of a month I was converted and would no more have given up sitting than brushing my teeth. It turned out that I didn't have to be good at meditating in order to be calmer and happier, I just had to do it. I also had more interesting thoughts, even though I was kind of trying not to think while I was meditating, and I could sit still better when that was called for. I got better at listening to my patients. Things that should have been funny, were funny.

A few years later I attended a meditation retreat with the Zen group my sister had joined (Pacific Zen Institute) and was MUCH better afterwards. I didn't like the fact that I never got enough sleep at the retreat (that is part of the routine, getting up at 4:30) and my knees and butt protested the sitting in one position for hours every day. But that actually didn't matter. I started to realize all sorts of really obvious things that made me happier. Life was more interesting when I got back home. I started writing, mostly poetry, which was kind of an extension of meditation.

During this first retreat I first made the acquaintance of a koan. Koans are brief stories or conundrums that make a person think, and then make the person realize that thinking will not work. They invite mental gymnastics and frustration and then unfold into something unexpected at some random time, days weeks, months or years after taking them up. Many students of Zen will go through a curriculum of koans with a teacher, with feedback from the teacher about whether the student really got the message that the koan was meant to give. Over generations and across continents, the messages that each koan gives are remarkably similar. I had no easy access to a teacher, in the wilds of rural Idaho, so I did my own koan curriculum, finding the most irksome koan, or one that seemed to specially talk to me, and chewing on it until all of the realizations that it seemed to have within it became clear to me. There is precedent for this, though teachers think it works better if you have a teacher.

During my second retreat I continued to work on koans, continued to sit and be sleep deprived, and had various transformative experiences which are better experienced than described. This recent retreat a couple of weeks ago helped me unwind a few delusions which now seem obvious but didn't before it started.

One of the other people there was a physics professor at one of California's state universities, and we were dinner cooks together. Like me, he came from a place of pragmatism and skepticism, and practiced meditation because it was one of those things in life that turns out to need doing. We tried to figure out, from personal experience, what it is in sitting and not thinking about a baffling ancient story makes our minds richer and calmer. Of course we didn't figure it out, but agreed that there was something about stillness that the brain needs. I also think that my mind appreciates having something to play with, and a koan is a good toy. Wiser folk than I have and still are thinking about what is important about meditation and why it does all these good things, so it is probably perfectly OK for me not to trouble myself with this question.

Apparently all Zen groups and all meditation retreats are not created equal, and I was probably lucky to have happened upon Pacific Zen Institute. I am violently allergic to that which seems unkind orinsincere, and some Zen groups have these elements. The US has a rich and diverse Zen tradition, with subtleties of practice of which I am, and will remain, mostly ignorant. Buddhist meditation is even more diverse, much bigger than just Zen, and includes a myriad of Asian teachings as well as very westernized forms like Jon Kabat-Zinn's mindfullness based stress reduction. These all have passionate proponents and do the peace and happiness thing for those who practice them. Doctors such as Herb Benson at the Harvard Medical School have tried to figure out how to bottle what is good about meditation for easy consumption by patients, some of them who have been failed miserably by standard health care. Although such medicalized meditation doesn't appeal to me personally, it is wonderful that it exists to help folks who need it.

Monday, February 4, 2013

How to become a locum tenens hospitalist and why you may or may not want to

Locum tenens (literally "place holder") is professional work done to fill in where help is needed. It is what I have primarily been doing for the last year, and has been an interesting ride.

When I decided to leave my practice related to losing a couple of partners and wanting to update my knowledge base and re-evaluate my career, I decided to do locum tenens work. I had always thought that having the skills of a physician would be able to allow me to travel and interact with places and people in a meaningful way, have adventures, roll up my sleeves, get my feet wet, that sort of thing. It turns out that this is true. Doctors with certain skills, especially internal medicine and hospital medicine, are wanted all over the country, especially in small towns and rural hospitals, and locums are hired often to avoid catastrophe while a hiring a permanent physician.

I have worked in California, Washington, Oregon, Idaho and Alaska in the last year and it has been really interesting and mostly gratifying. I have met new colleagues, made friends for life, seen lots of patients with mysterious and interesting problems and fascinating life stories and felt like I was useful and appreciated. I have also felt frantic and overextended, gotten lost, slept and ate less than was ideal.

There are many locum tenens agencies in the US that find jobs for physicians like me. They take care of helping facilities make sure that I am a legitimate doctor, not a serial killer or child molester, facilitate licensing in new states and make and pay for the arrangements that include travel, lodging and advocacy with the various organizations which hire me. For this they get about the same amount of money per hour that I do, so the client pays about double the amount that I am compensated to have me work. This is a LOT of money. It is a painful amount of money for the hospital to pay, so they really only use locum tenens doctors if they are desperate. Which means that, no matter how much they may like me at a given facility, they will rejoice when they can replace me with someone permanent. This means that I go to places, get to know people and systems, get good at them, am appreciated, then leave and never come back. They have the right to cancel my work within 30 days if they find someone cheaper to do it, and this has happened a couple of times. It is disconcerting, because it is often not possible to find new desirable work to replace what was planned with such short notice.

Becoming a locum tenens physician is easy: one simply contacts an agency online and then begins to fill out application forms and send countless documents to various places. It is time consuming but simple. Then a locums recruiter will call and begin to offer all sorts of jobs. If a job is interesting, the recruiter will send curriculum vitae information to the client and if the client is interested, phone interviews follow and if what they want is what the physician wants to provide, credentialing and scheduling follow.

I have found that different locums companies have different job opportunities and that I like some recruiters more than others. I have worked with Staff Care, CompHealth and Weatherby and have found them all to be honest and mostly easy to work with. The recruiter, though, makes money when I work, so they are all pretty proprietary about my time. In order to have a job when I want and where I want, I need to apply for more than one job at a time. If more than one comes through, I either have to work more than I want to or disappoint someone which makes me feel like a flake.

Full time work that pays much more than I made as a full time primary care doctor is 7 days a week, every other week, about 12 hours a day. This allows me to have real time off, which is great. Still, I spend lots of time on travel and lots of time away from my home, friends, family and dog. If I decide to do something creative in my off week, like attend a meeting or go on a trip, then I am away from home for 3 weeks in a row, which I virtually never did for the 20 years preceding starting locums. This is a little bit disruptive to anything that I have established at home, plus my dog gets really depressed.

Locum tenens work is a truly great option. It allows me to know that I will be able to stay busy in my field and make enough money to support my family and to have breathing space to do other important things. It is also not something that I will want to do as a primary occupation for very long.