inherit

For the Daily Prompt: inheritance.

Such soft colors. I am trying to capture the ferry wake color in the sunrise.

The news this morning and I am thinking of girls who are not believed and predators who are after them. And boys too. I am thinking of medical school, this essay.

I am thinking of the comment from a fellow male medical student, about the statistics of one girl in five sexually abused:  “I never believed it. I didn’t think women could be okay after that.”

There is still the idea in our culture of a woman “ruined”. Women are still not believed. Boys are assaulted, too. One in twenty. Here: http://victimsofcrime.org/media/reporting-on-child-sexual-abuse/child-sexual-abuse-statistics.

And in the end, I wonder, what are the adults thinking? It’s the woman’s fault for being pretty? It’s the girl’s fault for being vulnerable? The devil made me do it? I was tempted by evil? It isn’t my fault. I have money and power and therefore I can do whatever I want. Women and children aren’t people, I can buy and sell and use them.

I am so relieved to hear the news from Alabama this morning.

 

 

 

toxic people

Are there toxic people?

No, I do not believe so….

I think there are toxic interactions.

Toxic behavior. And it takes two to tango, really.

Do I have to stay away from someone who behaves badly? Do they set me off? Well, that’s about me, isn’t it? I need to go look in the mirror and see what is bothering me. What does this remind me of? Are they getting under my skin? So what part of my skin needs better boundaries?

I realized that my father drank too much when I was in college. I read about it and went home, ready to intervene. My mother and my sister refused, much to my surprise. And slowly I realized that my mother was enabling the drinking.

I set boundaries with my father. I said that he could not come to my house drunk and he could not drink at my house. I refused to sleep in my parents’ house because he was falling asleep and there were cigarette burns in the floor and an 8 inch diameter one between the couch cushions. I told my mother I was having nightmares about fires. She joked that she would be mad if he burned a hole in the waterbed. I told my father I was afraid to sleep upstairs and moved to my grandmother’s, two doors away. I was lucky that I had that option.

My father stopped drinking a decade later. I took my young son to visit, and found that my father had started again. I asked my mother, “Why didn’t you tell me?” She replied, “I told you I would leave if he drank, but I am not going to leave.” I said, “We are not staying with you.” and we moved to my mother-in-law’s house.

As a family doctor, I try to help each person. My clinic and I do have boundaries. If they no show for three visits within one year, we ask them to change to another doctor. People call for referrals often. I can’t do a referral without documenting a diagnosis and doing an examination, so they need a visit. “But you’ve seen me for hip pain!” “Yes, and that was a year ago. Time to reevaluate, right?” And all doctors here are swamped: they want to save their over busy time for people who truly need them. The orthopedist does not want to see that hip unless I agree that they need to: if physical therapy and discussion can fix it, one less person that they don’t get to operate on.

I recently had calls for an emergency referral. I left a message with both the patient and the specialist. I had not seen the person for five months. I have no idea what is happening. If it’s an emergency, they need to contact the insurance, not me, because I have not seen the person: no diagnosis. And insurance should cover if it is an emergency. If it is not an emergency, well…

There is behavior that I prefer not to be around. There is behavior I will tolerate in clinic but not my personal life, since I get paid in clinic. There is behavior I won’t tolerate in clinic. But think of the great ones that are still spoken of: the Buddha, the Bodhisattvas, Jesus. They had boundaries to where any person was allowed to approach them and was received and was sometimes changed by that reception. When I say “I can’t be around him or her,” how do I need to change? Ok, not the crazy person shooting into crowds, no tolerance. But day to day, the things that get under our skin, it’s our skin that is fallible.

I do not want to label anyone toxic. I hope to make a small difference in the world through my clinic. And add to the joy in the world.

For the Daily Prompt: saintly. I am not there. 

Sweet Honey in the Rock: Would you harbor me?

hypertension: The 2017 Clinical Guidelines

A visual guide to the new hypertension guidelines: https://www.medpagetoday.com/cardiology/hypertension/69399
In writing: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults
I don’t watch television news, so I always hear about these things from patients first. “What do you think of the new hypertension guidelines?”

“Haven’t heard about them yet, so I don’t know.” Seems pretty embarrassing really, doesn’t it? Shouldn’t I be alerted as a doctor before it hits the news?

First of all, these guidelines are NOT JNC 9.

What is JNC 9, you ask?

One of the messy complications of medicine for people in the US and in the world, is that there is not ONE set of guidelines. There are multiple sets of guidelines. Take mammograms, for example. The US Preventative Task Force* said that the evidence in their review could not differentiate between yearly and every other year mammograms. They said you could do it every other year. The American Cancer Society and the Susan Koman Foundation yapped and had different guidelines, do it yearly. So as a physician I have to not only pay attention to the guidelines but know who is putting them out. The radiologists wanted yearly mammograms too, surprise, surprise.

And do you think some of it is driven by money? Well, it’s the US.

JNC 8 is the Eighth Joint National Committee and put out guidelines in 2014. Their job is to review all of the big hypertension studies since JNC 7 and put out new guidelines. JNC 8 took over a year, was multidisciplinary, and the final document was 400+ pages.

They said that if a patient was over 60, their blood pressure should be taken standing up, and the goal was under 150/90. Under 60, sitting, goal under 140/90. Normal is 120/70 and below.

Then there are pages and pages of recommendations about which medicines to use and in special circumstances, that is: diabetes, kidney failure, heart disease, atrial fibrillation, etc, etc.

The cardiologists promptly started yelling about how JNC 8 is wrong and they put out a huge study saying that people have less heart attacks if their blood pressure is 125/80 or below.

But… the heart is not the only organ in the body. My patients are 77% over age 50 and 48% over 65. Once a person hits 80, their blood pressure may drop when they stand up. Most do. And low blood pressure, well, it’s bad for the over 80 crowd to get poor blood flow to the brain or to the kidneys or to faint and break things. That is why JNC 8 is multidisciplinary: because we need geriatrics and psychiatry and ortho and family medicine to be part of the guidelines.

So these NEW and IMPROVED guidelines. Well, who is putting them out? American Heart Association, American College of Cardiology, and a bunch of other mostly heart related organizations. And they are comparing it to JNC 7, not JNC 8. JNC 8 is being ignored. This document is a mere 192 pages, with the “short” version being 112 pages.

It says that blood pressure 130/80 to 140/90 is stage I hypertension, not prehypertension, and that we should treat it with lifestyle changes. Drugs are still to be recommended at anything over 140/90, though honestly, I start with lifestyle there too. Over 180/120 is now “hypertensive crisis”, consult your doctor immediately. 140-180/90-120 is stage II hypertension.

How will this change my practice? I am still thinking about the new guidelines and who has skin in the game. The AAFP (American Academy of Family Practice) put out a link to the guidelines and then a cautious comment to the effect of “We are studying how we should respond to this.”

Before this came out, I would tell people the JNC 8 goals. I do stand the people over 60 up, most of the time. I also tell people that the cardiologists want their blood pressure lower. And then that the cardiologists mostly ignore hypertension and cholesterol guidelines anyhow. If I follow the guidelines and then the patient sees a cardiologist, the cardiologist usually changes something. Guidelines be damned.

It comes down partly to a patient’s goal. I have people come in and say, “I don’t want to die of dementia!!” I see that as an opening. “What DO you want to die from?” People have different ideals. Some say, “I don’t want to die!” but then many do think about it. Sometimes this changes their ideas about what they want treated and what they don’t want treated.

Not everyone’s blood pressure drops in their 80s. Some people develop hypertension in their 90s. I tell them. They say, “I’m not taking a drug!”

I reply, “Let’s talk about strokes.”

They usually are not afraid of sudden death, but they don’t want the disability of a stroke. Many choose medicine after all.

One of the issues with guidelines is complexity. I could spend 20 minutes with a patient just talking about hypertension guidelines and choices of drugs and side effects and why they should be on an ace inhibitor or ARB if they have diabetes…. and there are guidelines for EVERYTHING. Sometimes conferences feel like all the specialists yelling: only half of diabetics are controlled, only one third of hypertensives are controlled, family doctors aren’t screening for urinary incontinence enough, osteoporosis, lung cancer, stop smoking! And then what my patient really needs is to talk about their adult child, in jail for addiction, and how frightened they are about overdose and the grandchild and the future…..

JNC-8 flowchart: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
JNC-8: https://jamanetwork.com/journals/jama/fullarticle/1791497
*lots of guidelines: https://www.uspreventiveservicestaskforce.org/