Monthly Archives: May 2022

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Shift or not?

Shift or not? Oh. I read it as swift or not. I am not going to shift from swift. It is too early to swiftly shift from swift to shift. Swift or not? Well, both. Not a swift as in the bird, but a swift and strong flier. Great blue herons always look incongruous to me in trees. They do like really big trees, but they always surprise me out on a branch. They have very light hollow bones compared to us and can sit lightly on a branch like this.

For the RDP: shift. I am swiftly feeling incongruously shifty on this early Monday.

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Finch Face

YOU thought I said “Fish face.” Fish faces came up at the wedding.

When my son is a baby, he goes with my husband for a well child check. I am in residency and can’t get away. The doctor asks, “Can he play patty cake?”

“No,” says my husband, “but he can make a fish face.” My husband has a long narrow face. He pulls both ears out and purses his lips. He wiggles his ears.

My son promptly makes a fish face.

“Good enough,” says the doctor.

My son has a small godson. They have mostly said hi on zoom. My son has taught his godson to make a fish face. When they visit in person, he makes the fish face and his godson’s face lights up. Oh, this is THAT person and they are REAL, not just on a screen!

The godson is the ring bearer at the wedding last Sunday. I tell him I am his godfather’s mother and make a fish face. Then I call my ex over. He makes a fish face and the godson is delighted. All of these talented people at the wedding! Who know about fish faces!

For the Ragtag Daily Prompt: faces. Very Happy Mother’s Day to everyone, who is a mother, has a mother, is a grandmother, has a grandmother. I could go on.

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Normalizing our behavioral health response

I keep seeing headlines: MENTAL HEALTH IS WORSE. TEENS ARE STRESSED. ADULTS ARE STRESSED. DRUGS AND ALCOHOL AND DOMESTIC VIOLENCE ARE UP.

Like they shouldn’t be? This isn’t news. It is expected, because we are in a pandemic, the death rate is up, people are frightened, the scientific news changes daily and now we add a war.

OF COURSE PEOPLE ARE ANXIOUS AND STRESSED. And when stress goes up, substance “overuse” goes up too. Add fenanyl to the mix and the overdose death rate is up. Should I call it the “overuse” death rate to be politically correct? I do think that it is stupid to stigmatize “overuse”. But I also do not like the term “overuse”. Addiction may be stigmatized, but to me addiction means the drug or alcohol or gambling has taken over the person’s brain and it is the addiction that is lying to the person and to me. It makes it much easier for me to watch for relapse if I think of it as the habit or substance in control. There is no stigma there: the person is deeply ill and needs help. Part of the help is recognizing relapse. I look for signs.

With behavioral health we learn to watch for signs. The latest guidelines say that we should screen for behavioral health problems at well people visits. One in ten people are depressed and the lifetime incidence is higher.

The online and news articles sound surprised that there is an increase in behavioral health problems. Why would anyone be surprised? We have evolved emotions along with logic and emotions help us to survive. If you are a child in a war zone or a family with abuse or domestic violence, your brain wires to survive the crisis as best you can. These are ACE scores, Adverse Childhood Experiences. Every child’s ACE score is going up during the pandemic. Adults can develop PTSD, depression, anxiety: of course. This is how our species survive. It isn’t FUN but it is not a disaster either. We can help each other. We can listen to each other. We may have to say “I can only listen to this for ten minutes,” and set a timer. There was a cartoon with a father with a stop watch. The daughter is complaining as fast as she can. He stops her: “There. You have had your one minute of whining today.” Limit the news if it is driving you bananas or you feel more depressed or frightened. Turn off the television: if you live in a safe place, go for a walk. I have goldfinches and pine siskins arguing with each other in my front yard. The cats are hugely entertained by this. The cats only go out with harness and leash. I may need to follow Sol Duc up trees. She leaped on top of the outdoor cat cage yesterday, four feet up. I was surprised. No wonder they can catch birds: from a stand to four feet up and she is about ten months old. And see? We are distracted by the cat and relax a little.

If you are not trying to escape a war zone or something else horrible, give yourself the gentle gifts: things that make you relax. Stupid cat videos, old music, reread a beloved book, a gentle walk outside. Yesterday I “walked” Elwha. He spent the whole walk sitting on the porch watching the birds. Two birds landed in the grass and he immediately morphed to hunter, but was still on a leash. I saw a pair of robins in the back yard. One was holding something in her beak. A gift for the other? Nest building? Nestlings already?

My other go to is the trees. I go lean on a tree when I feel overwhelmed. The trees do not seem to mind. Rocks don’t either and I am very grateful.

Blessings.

Our rhododendrons are blooming.

#ACE scores #behavioral health #emotion #fear #normal emotional response

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from blue to breathe

I attended a medical conference on line yesterday and today and it made me very blue. At first it just frustrated me, because it is about increasing behavioral health access. Isn’t that a good thing? Yes, but they completely missed the biggest barrier for primary care: TIME.

With the current US medical corporate money extracting insurance non-caring system, primary care is increasingly forced into 20 or 15 or 10 minute visits. I fought my hospital district when they said “See patients for one thing only.” I replied “That is unethical and dangerous: if it is a diabetic with an infected toe, I HAVE to check their kidney function, because antibiotic dose must be adjusted if their kidney function is reduced.” And there are at least two and maybe three problems there: infection, and if the diabetes is out of control that worsens the infection, and then kidney function. And actually I have to be sure anyone going on antibiotics has good kidney function or adjust my dose. I am very very good at this, but it takes time. I can work with complex patients, with veterans, with opiate overuse, with depression: but none of this is a simple template slam dunk. A study more than a decade ago says that the “average” primary care patient had 5 chronic illnesses. My patients don’t want to come in for each one separately and anyhow, if they have kidney problems I have to pay attention when I pick medicines for their high blood pressure. None of it can be separated out. That is why medicine is complicated.

Someone asked why can’t I just post the price of a “simple” visit for a sore throat. But a sore throat can be viral, can be strep A, can be a paralyzed vocal cord, can be a throat abscess, can be vocal cord cancer. I can’t tell ahead of time. I can’t. Early on during covid, a patient called and wanted a Zoom visit for abdominal pain that he said was constipation. I said “No, I can’t do abdominal pain over Zoom safely.” I can’t ASSUME it is constipation. It was appendicitis and he had his appendix out that evening. He called from his hospital bed the next day to thank me for making him come in.

The conference made me blue because they ignored my questions about why they were not advocating for primary care to have more time with patients. They claim to be all about change, but changing the US medical system? Nope. Do not want to talk about that. But I do want to talk about it. You can help by letting Congress know: single payer or medicare for all. That insurance company gets 20 cents of every dollar to profit and wastes tons of money forcing doctors’ offices to call for prior authorization. And if we have single payer, think of all the small businesses that will start because the terror about health insurance will disappear! I think it would reduce everyone’s stress, except the insurance CEOs. And they have earned more than enough, goodbye greed.

I am also tired of specialists telling me that primary care needs to do MORE. When I get told that I am not doing enough about hypertension, bladder leakage, depression and stopping smoking, and then 20 other specialists lecture me. Ok, so one minute per topic to fulfill what all of them think I should do? I want a primary care conference where primary care doctors are celebrated: cases are presented where the specialist says what a brilliant job the primary care doctor did.

I received a consult letter from a cancer doctor a few years ago. He wrote that I had diagnosed the earliest case of chronic leukemia that he had ever seen and that he was impressed and the patient would do fine. That’s the conference that I want to go to: where primary care and specialists talk about that and we inspire more doctors to do primary care.

You can learn more and how to talk to your congressperson here: HealthCare Now: https://www.healthcare-now.org/

or at Physicians for a National Healthcare Program: https://pnhp.org

And put your vote and your money towards healthcare, not health insurance.

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April A to Z reflection

April was a very interesting month! I went to Europe for the first time since 1988 and got covid, so had to stay an extra 8 days. The version I got was a mild cold and my lungs did not get worse. Traveling on oxygen is really challenging. I was anxious to get home because my son and daughter-in-law got married after postponing in 2020 and 2021, so they married on April 30th! It was a wonderful wedding!

So, I had to do some planning for the A to Z, writing about women artists, mostly Helen Burling Ottaway, my mother. I took a number of my mother’s etchings to give to friends in Europe and used those because they were what I had. In typing up her resume, I learned more about her! She was a prolific artist and I want to get more of her art out there. I had originally planned to set up an on line shop of her work, but the Europe trip, covid and the wedding derailed that idea! I still want to do that, but I am a bit slow about it. I need to catalog and photograph her work, after I recover from the wedding extravaganza.

When I got home from my trip on April 12, I started doing two posts a day. I did the present letter and then worked from the end of the alphabet, setting up Z for Zarathustra to go live on April 30th. By the last week of April, I had it all set to go live day by day. This is good, because there was no way I would have posted from the last Wednesday on!

I did not get to surf other writers blogs as much as I had planned. Too busy in Europe and too busy with wedding. This week I mostly want to do not very much. I am sorting wedding photographs, the ones I took, and sending them to the new bride and groom.

The picture is of my two aunts at the music rehearsal. I was cantor and led the two hymns. Both of my father’s sisters are church organists. They played four hands for the processional and the recessional and were wonderful! With both my parents gone I was very very grateful to have them present.

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what would YOU choose?

Here is a story of a choice about an abortion, a theraputic abortion, where a mother has to make a difficult choice. I have seen Family Medicine patients since 1991, so this will not identify a particular person. No HIPAA problem.

I see a new patient in clinic, a woman, who already has children. She has back pain. All is routine until she says, “Sometimes my leg goes numb from the knee down.” I stop. This is NOT normal. “Completely numb?” I say. “Not patchy?” “Yes.” “How often?” I ask. She shrugs. “Not very.” “If it happens again, call me and I want to see you right away.”

Why? This is unusual because most numbness follows dermatomes if it is from back pain. The dermatomes on the skin wrap from the back down the leg all the way to the toes. When someone describes numbness or the pain of shingles in that distribution, we know which nerve is affected. Numbness from the knee down can come from diabetes and other causes, but it is not on one side and it doesn’t come and go. So the unusual stands out for me.

“Anything else weird?”

“I had vision problems in my last pregnancy. They sent me to specialists, even a neuro opthamologist. He couldn’t find anything.”

“Ok.” I shrug. We move on.

She calls two days later. “Both legs are numb from the knee down.”

“Come in today,” I say.

Both legs ARE numb from the knee down. She also can’t lift her feet. The muscles from the knees down are weak. I get neurology on the phone. “MRI her from the top of her head to the base of her spine.” I call the hospital and set it up. That day.

She has seven brain lesions suspicious for multiple sclerosis. She did have an MRI in the previous pregnancy, which was negative. I do not remember how old the child was, 2-4 years or more when I saw mother.

I call her back in for results, we talk about specialists, and I call a neurologist in the nearest big city, three hours by car from where she lives. We start medications and my patient is scheduled.

She has multiple sclerosis. The flare improves. The visual symptoms were MS in the previous pregnancy, but it was not yet visible on brain MRI.

Then she gets pregnant again. Her symptoms immediately flare. She comes to me and I call the neurologist.

The symptoms are not a little worse. Much worse. “I suggest she terminate the pregnancy.”

My patient is horrified. Until the neurologist’s next words. “She needs to terminate if she wants to be able to walk for the children she has.”

My patient chooses an abortion, to terminate the pregnancy. Because she has a bad version of MS*, she remembers the symptoms in the last pregnancy, she is young, she is clearly progressing and she wants to take care of the children she already has.

What would YOU choose? For yourself, for your sister, for your wife. If you are male, do you have any right to make that choice? Now picture yourself pregnant with that choice. And thank you for reading this.

*Addendum: present evidence says that multiple sclerosis does NOT worsen with pregnancy. However, another illness, NMO (neuromyelitis optica) instead tends to become more active in pregnancy. It previously was lumped in with MS until the antibodies (anti-NMO) were identified and it was realized it’s a different subtype of demyelination disease, with its own treatment options. Medicine changes over time and the woman, the neurologist and I were working with the information available at that time.

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speaking up

A friend says he does whatever he wants. He refuses to answer questions about how he makes his money. He doesn’t care if this annoys people. I suspect he may enjoy it.

I have one of those public jobs. Well, had. I have now been disabled from Family Medicine for a year. My lungs are much better than a year ago but they are not normal. And I have now seen 17 specialists and 3 primary care doctors since 2012. The consensus is “We don’t know.” Though many specialists are not willing to say that. What they say instead is, MY testing is NORMAL, go to someone else. My lungs are not normal, but I am on my fourth pulmonologist. I saw a cardiologist this year and the first thing he says is, “It’s your lungs, not your heart.” Well, yeah, I know that.

I miss my patients, but there is something freeing about not working. Ok, more money would be nice, but I am doing ok. Meanwhile, I am thinking about what to do now. I can write full time. Write, make music, travel (on a budget) and sing. And speak up.

Doctors have interesting portrayals on television. We went from Dr. Kildare to Dr. House, working our way through the shows with an emergency room and medical residents. ER drove me nuts. No one EVER dictated a chart so at the end of each show I hyperventilated at the hours of paperwork/computer/dictating they had left. House interests me because it’s always the thing that the patient is hiding or lying about that is the key. “Go search his apartment.” says House. I have figured out cases by getting permission to call family or a group home. More than once.

But a physician is a public figure. I had been here for less than a year when a woman comes up to me in the grocery store and says “What are my lab results?” I look at her blankly. I can’t remember if I really did the snappy comeback that comes to mind: “Take off your clothes and I will see if I remember.” I respond politely and she says, “Oh. I should call the office, right?” “Yes, I try to leave the work there,” I say. If a particularly difficult person was bearing down on me, I would whisper “cry” to my kids. That worked. They would act out on cue and I would be the harassed mother. The person would back off.

I am in a small town. We have three grocery stores. I see patients everywhere, now that it has been 22 years. If I remember every detail, that means they are or were really sick. And we have the layers of relationships: someone might have kids the same age or work with boats or be in chorus with me. Once I take my daughter to a party. The mom introduces me to two other mothers. “She’s my doctor,” says the introducing mom. “Well, me too.” says the second. “And me,” says the third. We all laugh.

Once I am visiting my brother outlaw’s bicycle shop. He has a customer. The customer starts talking to me too. Brother outlaw says, “Do you two know each other?” The customer eyes me. I have my neutral doc face on. “She’s seen me NAKED!” says the customer and I howl with laughter. What a great reply. And my brother outlaw gets it.

Docs have to pay attention to HIPAA. When three women say that I am their doctor, I reply, “Yeah and I left my brain at work, so I can’t remember a thing.” Those three were healthy, so I really do not remember labs or the results of a pap smear. Once I was in cut off shorts and waved at an older woman who was at the ophthalmologist’s. She sniffs and looks away. I get the giggles: I think she did not recognize me. My town is only 10,000 people, so after 22 years I have taken care of many of them. Though sometimes people thank me for taking care of their mother, and after it sounds unfamiliar I ask if they mean Dr. Parkman? Oh. Yes. People get me mixed up with two other small Caucasian woman doctors.

I started the “outfits inappropriate for work” category last year when I was still very sick and short of breath and on oxygen. I did not go out much, partly to avoid covid. My pneumonia was something other than covid and it was my fourth pneumonia and I should not need oxygen. Now I’ve had mild covid and the oxygen is only part time. I sang at my son’s wedding, off oxygen, so I can sing off oxygen for a short time. I danced off oxygen too and did get QUITE short of breath. Since I am no longer a public figure, I can speak out and speak up more. I am thinking about that, particularly with the recent Supreme Court news. I do not agree with what they seem to be planning.