Category Archives: anger

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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.

 

 

 

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loyal

For the Daily Prompt: loyal.

I am thinking of the men working with the Weinstiens and the Cosbys. They might have heard a rumor, but they ignored it? Women are free to speak up if there is a problem?

No, gentlemen, actually women are only “free” to speak up if they are rich and in massive groups.

Otherwise, we are dismissed, silenced, disbelieved and ignored.

For me, it was at age 7. Are you going to say I was dressed wrong? I was too sexy? I should not have been alone with him? It’s my fault?

The water is beautiful and reflects the sky. What do you think is there beneath the surface in the depths?

 

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the unwashed masses

I don’t have any of THEM as patients. The unwashed masses. All of my patients are smart.

There aren’t any unwashed masses.

I have a gentleman who is overweight, obese, diabetes. He is not stupid. He is not unwashed. He is not exercising or controlling his blood sugar right now because the temperature is below freezing. He has a hole in his trailer floor and no heat. So he huddles under the electric blanket.

I have a gentlewoman, also diabetic. She too is not stupid. She is not unwashed. She lost her husband to cancer and then everything else and then was homeless for a period. She has a small house but she has no heat. She stays in bed to stay warm. Her contractor quit before he put in the furnace and he’s gone bankrupt. She is cold.

I have veterans. They are not stupid. They are not unwashed. One was homeless for a long period and pooled his resources with another to rent a section 8 house. I am so proud of them. They are having trouble living together, each would rather live alone. Only sometimes they would rather not be alone. It is hard.

I have a massage therapist. She started to train as a counselor. To be a counselor, she needs a certain number of supervised hours and was getting this through the county mental health. “I didn’t know.” she says. “It is taking twice as long as I thought because half the time they don’t show up. They don’t show up because they don’t have gas, they don’t have food, they have been evicted, their son is in jail, they are in jail. I had no idea. My massage clientele is so different, they pay. I thought poverty was in third world countries, but it is here, in my county. I didn’t know.”

I know the people who live in the woods. A schizophrenic who comes once a month for his shot. He was losing weight. “Why are you losing weight?” I demand. “I am only eating once a day.” he says. I nag him to go to the community meals. He is shy, he is afraid of people and he is hungry. He is not stupid. He is not unwashed.

I have opiate addicts. Six years ago one expressed concern. He is 6 foot 5 and big. “I am afraid of some of the other people. You shouldn’t be doing this! It’s too scary and dangerous!” My opiate addicts are not stupid. My opiate addicts are not unwashed. Sometimes they relapse. Sometimes they die, in their 50s, 40s, 30s, 20s.

One in six people in the US is below the poverty level. They are not stupid. They are not unwashed.

And when someone talks about the masses, the people, the stupid people, most people are stupid, the sheep….

….I am beyond angry….

….my heart hurts….

Poverty in the US: http://www.census.gov/newsroom/press-releases/2016/cb16-tps153.html.

More: http://www.census.gov/topics/income-poverty/poverty.html.

The examples are taken from 25 years of practice, details changed for hipaa, but I can list dozens at any one time. The photograph is during the sunset after clinic, when I walked down town, the view across the sound.

 

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Your health care dollar

I have been writing posts about fraud in medicine: but I think I am using the wrong title. Instead it should be your health care dollar: how the US medical corporate system wastes your health care dollar.

Think about it. What do you want to spend that dollar on?

Do you want it to go to 1300 different insurance companies and their web sites, their advertising, their competition and their profit? Do you want your healthcare dollar to go to complex coverage rules and contracts, to forms for prior authorization, for the weekly postcards and emails that they send me telling me that they have changed your coverage? Is it any surprise that I have no idea if your insurance company covers a test? They may have last week and not this week. The overhead for medicare is 2-3% administrative costs. Now why would we privatize that when the overhead for the health insurance companies is 20-30%?

How much of your health care dollar do you want to go to corporate competition?

I don’t want ANY of my health care dollar going to corporate competition and profit. I want my health care dollar going to my HEALTH. We spend the most per person in the world, almost twice as much per person per year as the next most expensive: and we don’t guarantee care. Hello, the next most expensive and all of the other nearly 40 countries, first and second world, have universal care for all their citizens. So is our care twice as good?

No, no, no, and no.

Hello, new administration. Let’s put the health care dollar where it is paying for health…. in medicare for all and in a single payer system. We have guideline after guideline on how we should treat illnesses, here:

US Preventative Task Force

The guidelines are regularly updated. If we have medicare for ALL then I will KNOW whether a test is covered or not. I have memorized the entire list of medicare covered screening tests and all the details: screen for abdominal aortic aneurysm is covered in male patients age 65-75 who have smoked more than 100 cigarettes in their life and any patient who has a family history. I have the whole list in my brain.

You CAN make a difference. Write to your congresspeople, state and national. Call them. Email them. They all have websites. Tell them YOUR health care story or the story of a friend or family member.

Join Health Care Now and Physicians for a National Health Program.

I want my health care dollar to go to HEALTH CARE.

For the Daily Post Prompts: gone and interior. Interior because I am so angry at the poor spotty costly health care for my fellow people in the US. And gone: your health care dollars is GONE: let’s use the next one wisely.

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Doctors don’t charge for phone calls

Doctors don’t charge for phone calls.

Attorneys do: they charge in fifteen minute increments.

Doctors don’t charge for phone calls: oh, but actually that is a myth. And it’s raising the cost of health care in the US because the insurance companies are using this myth to their advantage. Not only is this costing every one of us more money, but it is driving doctors out of practice. And it’s making patients bitter and angry at the doctor, when it is the insurance that should bear the blame…

Why do I say this?

A patient calls their health insurance. “I need x.”

The health insurance says, “Have your doctor’s office call for a prior authorization.” Now, we are definitely paying the health insurance to have someone say that to the patient.

The patient calls the doctor’s office and requests the prior authorization. There, a second person is being paid to get that phone call.

The doctor’s staff runs it by the doctor. The doctor says, yes, the patient needs that or no, I would like a visit to discuss this. More time that we pay for.

If the doctor says yes, the doctor’s office contacts the insurance by phone or on line to do a prior authorization. This means a different website for every one of 1300 insurance companies in the US. We are paying the doctor’s office staff to be on the phone and on the computer to fill out prior authorization forms to get permission from the insurance if your doctor agreed that you need x or that x would be helpful. We also are paying for all of those websites that the insurance companies have to slow down giving the patient care.

I don’t have an office staff to do this. I have a bare bones clinic so that I can spend more time with patients. I call the insurance myself with the patient in the room.

More than half the time the insurance company says that x is not covered under the patient’s plan.

But wait. The patient already called the insurance to ask if they could get x. And the insurance said have your doctor get prior authorization. So in the usual office, the patient is called and told that x is not covered. The patient is angry, because they think that the doctor’s office has messed up the prior authorization. The insurance does not want to tell the patient it is not covered. So our costs spiral up and up and up, because the insurance has realized that they would rather have the patient angry at the doctor’s office, not the insurance.

And we all are paying for it with our health care dollars…..

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On death and feelings

When my mother was dying of cancer, she did not want us to cry.

So we didn’t. We had her at home in hospice for nearly six weeks and we did not cry. Almost.

My sister called me. “I started crying today, at the kitchen table.” My mother was in another room in the hospital bed. “Everyone left. No one stayed with me. Everyone left.”

I didn’t cry but when people called to say how were things, I couldn’t speak. I sat there with the phone, silent. Because what I wanted to say was my truth and I knew very well that that was not what they were calling to hear. So I did not speak.

After my mother died, time passed. I felt…. many things, but the strongest one was “I wish my mother had let me cry.” We did what she wanted. But I wanted to cry.

My sister got cancer and fought it ferociously. She refused hospice until the last week. I flew down three times in the last two months.

Six days before she died, her friend and I were helping her. “I’m sad!” said my sister.

“Don’t be sad.” said the friend.

“It’s ok to be sad.” I said. “What are you sad about?”

My sister started crying: “I won’t be at my daughter’s high school graduation! I won’t see her get ready for prom! I don’t want to leave her!”

“You won’t leave her.” I said. “You will be there. Not in this form.” I meant it absolutely.

“I want to stay!” she said.

“I know.” I said. “I am so sorry.”

With my sister, I did not do what she wanted. I thought of my mother and that I wished she had let me cry. With my sister, I tried to listen to what she wanted and listen to what I wanted. I tried to be honest with her. She even got mad!

But… I watched her go in the cancer bubble. Where fewer and fewer people were being honest. They were afraid. They did what she wanted. They wanted her to be happy. And she tried so hard….

When I had arrived for the last visit with my sister, she was sitting with my cousin. I hugged her. She was not speaking much. I asked if she would like me to sing something and she nodded. I started singing “I gave my love a cherry”, a sweet lullaby. My sister shook her head, angry and fierce. I studied her. “How about Samuel Hall?” I said. My sister smiled and nodded. I started singing “My name is Samuel Hall.” It is about a man who is going to the gallows for killing someone and he is entirely unrepentant and angry. My cousin looked at me, startled. “I haven’t thought of that song in years,” he said. We both sang it to my sister. “To the gallows I must go, with my friends all down below, damn your eyes, damn your eyes.” That was the right song, angry, resisting, raging. “Hope to see you all in hell, hope to hell you sizzle well, damn your eyes, damn your eyes.”

I flew back to work three days before my sister died. I am told that she was scared when she died. “I said, don’t be scared.” said a friend.

Why not? I thought. Why can’t the dying be scared, be anxious, be angry? Why are we afraid to let them? I would have said, Why are you scared? And I would have said, I am scared too. And sad. And angry.

I told my counselor once that my husband was on the couch, angry, and I had to leave the room.

“Why?” she said.

“I am afraid.” I said.

“Why?” she said.

“I am afraid he’s angry at me.” I said.

“So what?” she said.

I thought, so what? “I want to fix him. I want him to not be angry.” Even if it isn’t at me.

“Why can’t you stay in the room?” she said.

I practiced. I stayed in the room. He was angry, grumpy, acting out. It’s not my anger. I don’t have to fix it. It may be just or unjust. Does it really matter? It is his anger not mine. I can stay present.

A friend said that his friend was dying leaving small children. “He was so angry that almost all his friends stopped visiting.”

A man and his sister are not speaking four years after their father died because they disagreed so strongly about how his lung cancer should be treated.

An elderly woman in the hospital agrees to go home for care with her son when he is present and with her daughter when she is present. When neither is present she will not make a decision.

A woman says to me that she is angry that hospice didn’t tell her which drug to give at the end to keep her friend from being anxious.

I hope that we learn to stay present for the dying and for the living. For all of the “negative” emotions. I see most of my hospice patients want LESS medicine rather than more. As their kidneys fail, the medicines last longer. They do not want to be asleep. They may cry. They may be angry. They may be unreasonable. Why should they be reasonable or nice or peaceful?

We want most to be loved entirely. Even when we are sad or whiney or angry or anxious. Who wants to be left alone when they are afraid? I hope we all learn to stay present.

And when we were alone, in that last three days, my sister said “I’m bad!” I said, “You are not bad. You’ve done some really bad things.” She said, “I’m sorry.” I said, “I love you anyway.” And she lit up like a buddhist monk, like an angel. And we both cried and I am so glad I was there.

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All of my patients are smart

I am a rural family practice doctor for over twenty five years and all of my patients are smart.

All of my patients are complicated.

I don’t mean that they all have degrees or PhDs or are intellectuals. I mean that they are smart in all sorts of ways.

I was talking to the UW Pain and Addiction Telemedicine Team four years ago. I said that when I had a new chronic pain patient who is angry about the law in Washington, I would give them the link to the law: http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement.

“You give them the link?” said one of the faculty. “But they can’t understand that.”

“Why not?” I replied. “I did.”

This was met with silence. My attitude is, well, I am a physician. I am not a lawyer. Yet I have to follow the pain law. Actually we all have to follow all the laws in our country. We say ignorance of the law is no excuse. Yet then the attitude of the pain specialists at UW was that the law is too confusing for my rural patients.

I think UW is wrong and I think that it is disrespectful to patients. Treat them as adults. Treat them as smart. Treat them as if they can understand and you will get respect back. And if they trust you they will then tell you when they do not understand or need something translated from medicalese to english.

I worked with a patient who works every day. She is in a wheelchair, a motorized one. She has cerebral palsy and can’t talk much. And she is smart too.

This election is about the United States population being smart. They know something is very wrong and they want it fixed. I think that Citizens United needs to be taken down. Corporations are not people, unless the CEO can be the physical representation of the corporation and go to jail when the corporation lies and steals. Wells Fargo, I am talking to you. I am taking my money to another bank. Pay reparations. The United States population is sick and tired of the rich getting richer and corporations stealing from people for profit. Democrats and republicans are sick and tired of it. We are not going to take it any more. If you have gotten rich from corporate underhand theft, lies and confusing regular people, give the money back. Because you can buy an island, but if the United States population rises up to hunt for you, there is no where in the world you can hide.

It is time for corporations to give the United States population the government back. Or we will take it. Because every patient I have ever taken care of in over twenty five years is smart. That is not to say we don’t all do stupid things. And some people won’t change. But in the end, everyone can learn and everyone can change.

I took the photograph in Larrabee State Park in September. This tree is down: but it is not a nurse log yet. It is not dead. The roots are still providing nourishment and it is sprouting branches all along the downed trunk.

 

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Playing Poker with Putin

People keep saying, “I don’t TRUST Hilary Clinton.”

And they say, “Her smile is not sincere.”

I am confused and dumbfounded. Uh, I thought that is the POINT of politics. NAME A POLITICIAN YOU TRUST.

I DON’T TRUST ANY POLITICIAN.

So here is a game: Playing Poker with Putin.

This requires three people, of any sex.

Player 1 is Hilary Clinton.
Player 2 is Donald Trump.
Player 3 is the moderator who in this case happens to be Mr. Putin.

NOW. The moderator begins to ask questions. Every time the moderator asks Hilary a question, Donald interrupts. Donald, you can be as foul and rude as you want, though you should not swear, because you are on national television. You can talk about “lady parts” and the size of your hands. And all the rest of it.

Putin: go for the jugular on everyone.

Hilary: you have to smile. The entire time. You cannot object to being interrupted, because that is bitchy if you are a girl and manly if you are a man. You cannot show anger. You cannot show any emotion at all except a totally sincere smile no matter what the two men say and no matter how many times you are interrupted.

If the person playing Hilary loses her temper she (or he if a guy is playing the part) loses. Then Donald and Putin have to stage a mock battle throwing pillows at each other and insulting each other’s wives. At the top of their lungs. Be as mean as possible. Then Donald will turn the country into a dictatorship because “I have to be equal to Putin.”

So….my definition of politician is someone who can keep their head no matter how nasty the conversation gets. No matter how many lies are told. No matter how many insults are given. And you do the best you can in office to represent the entire country and for the good of the world.

Play on, Hilary. You win Best Politician Ever in my book.

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Fraud in medicine: why “help” won’t help

This article:  Doctors wasting over two thirds of their time doing paperwork showed up on Facebook yesterday.

The problem is that “hiring people to help with paperwork” will not help.

Why? We’ve already done that and it’s a huge mess.

For example: I was referred to an Ear Nose and Throat Specialist at one of the Seattle Mecca hospitals. I had to travel two hours and then in the waiting room I was given a four page patient history to fill out. I filled it out. I had been referred by a Neurologist, who sent a letter and note. After I filled out the forms, HIPAA and “you will pay if your stupid insurance won’t” and address and consent to be treated and yada yada…. I waited.

At last I was shown to a very luxurious room. There a medical assistant asked me many of the same questions that I’d filled out on the form and which were already in the letter and note from the neurologist. She typed these into the EMR- electronic medical record. Then she left. And I waited.

At last the distinguished otolaryngologist entered the room. He said, “I see that you are here for chronic sinus infections.”

“No.” I said. “I am not.”

Silence.

“I see that you did not read anything I filled out and I am a physician and I drove two hours to see you.”

Silence. “Um.” he said. “Uh, why are you here?”

“Strep A sepsis twice and we want to know if my tonsils should be removed.”

Right. So… all that paper you fill out before the physician saw you? Yeah, like, my impression is that physicians don’t read it until after you leave. And maybe mostly don’t EVER read it.

I plan to find out the next time I have to see a specialist. I will write “you don’t read this anyhow, so I am not filling this shit out” on page 2 and see if the specialist notices. Bet you money they don’t. Though when they yell at their staff for not entering my medication allergies or the review of systems, they might notice.

So… I am a primary care physician. What do I do?

A new patient has one form: name, address, insurance information, hipaa and “you pay if your insurance doesn’t”.

I do the health history myself in the room entering it in the first visit, which takes 45 minutes to an hour. WHOA! INEFFICIENT! Nope. Actually it is brutally efficient. For four reasons:

One — I enter it myself and ask the questions myself and I am really fast at it.

Two — now I know the person, because I went over all of it: complaint, history of present illness, past medical history, social history, allergies, review of systems, and I ask people to bring all their pills including supplements to the first visit and I enter them too. And I look at the bottles. I don’t like vitamins with 6667% of the Recommended Dietary Allowance of any vitamin, lots of vitamins now have herbs in them too and I would not recommend taking cow thymus, labeled as bovine thymus.

Three — Now I don’t have to spend time reading forms filled out in the waiting room or a history entered by someone else, because I don’t have time to do that anyhow. I did it all in the visit. I will still have to read old records and any labs or xray results or consult notes or pathology reports and hey, where do you think the waiting room paperwork falls in that priority list? Yeah, like never.

Four — I hand people a copy of the note as they leave and ask them to read it and to bring corrections if I got it wrong. They go from thinking that I am a drone staring at the laptop to saying, “Hey, she typed nearly everything I said (and she has three spelling errors).”

Because the truth is that medicine is really complicated now and it just doesn’t help to have more people “do the paperwork”. I have to read the notes and labs and reports myself, because I am the physician.

There are three things that WOULD help:

1. One set of rules. Hello, the insurance companies, all 500ish of them send us postcards and emails every week saying “Hey, we’ve changed what we cover, meaning we cover less and we have new improved and more complicated prior authorization rules! Go to our website to read all about it.” Guess how often I have time to do that. NEVER NEVER NEVER. I read medicare’s rules. So medicare for all, single payer is partly to have ONE SET OF RULES. I can memorize miles of rules, but not if they are changing in 500 companies every week. Shell game. Also, prior authorization means “your insurance company is making your doctor fill out paperwork in hopes that they can delay or refuse the care your doctor thinks is best for you.”

2. One electronic medical record. Right now there are about 500 of them too and none of them talk to each other so we are all “paperless”. Ha. It’s worse than ever, because we get 100 pages or 200 or 300 of printed out electronic medical record for every single new patient. I need two more big file cabinets for my “paperless” office. Hong Kong did it in 9 months. What, are we wimps? Make a decision.

3. Standardization of lab and xray and home health and physical therapy and nursing home and rehab and hospital order forms. Because every stupid lab form is different: not only arranged differently but also the lab panels are different, the requirements for what that lab wants to fill the order is different and the results are arranged differently on the page. Hello. Stupid, right? Any efficiency expert would laugh.

And that’s how we could really help doctors help patients.