Category Archives: anger

by

Fraud in medicine: medicare application

Medicare quit paying my clinic at the end of July, on the 31st.

I was still half time in clinic, we were interviewing a new receptionist as my receptionist of five years wanted to retire by August first. We got some sort of notification from medicare, but their letters are very cryptic.

My new receptionist was needing orientation and help and I was really tired after July. I redid the medicare application and sent it in. We continued to see medicare patients and turn in the bills.

Our medicare contractor is noridian. They sent us a cryptic letter saying that something was wrong with the application. This was, mind you, a renewal. I had been seeing medicare patients for five years in my clinic.

I call them. I am given a name and a number to identify the call. I have two Ptan numbers, one for me as a physician and a second for the clinic. The first call said that my personal Ptan application was correct but the clinic one wasn’t.

I did it again and mailed it. Second day air. He said that our payments should be released in 10-14 days.

Ten days. Nothing. Fourteen. Nothing. I am pulling from savings to run the clinic. I call a second time. Again I am given a name and a number. She said I had to CALL to get paid once the application was received. I said the first guy didn’t say that. She said another 10-14 days.

We wait. After ten days I call. A third number and person. Once again I have a cryptic email. I ask about the PTan number on the email, which is not my clinic’s Ptan number. Oh, says the man, that is what is wrong with your application. He says to do form (numbernumbernumber B) not form (numbernumbernumber A). And it will be 10-14 days after they receive it.

I do it AGAIN. I do notice that all of the old copies of the form in our file have the PTan numbers wrong. Weird. They have been paying me for five years.

Ten days. I call a fourth time. She says that it will be 30 days not 10 to 14 until medicare lets me know if my application is correct. Or they might pay me after 10-14 days. They aren’t, so I argue that something must still be wrong. What is it? She can’t tell me. I want a supervisor. She says that I can talk to a supervisor in 10-14 days. We figure out that the Ptan number on the application is correct. I say, “I am writing my congresswoman.” and hang up.

So I do. I find my Senator’s email and I write to her. I have been a rural family practice doctor for 25 years and I saw a 98 year old yesterday and a 91 year old today and I LIKE my elderly patients, but I have HAD it with medicare, at least with the contractor noridian that is running medicare for my state. I list the phone call dates and names and identifying numbers and I say FIX IT because otherwise I am for the first time in 25 years seriously considering quitting medicare.

Two days later noridian sends an email saying they are releasing my payments.

The next day we get a direct deposit for $9000.00. That is a START.

One week later we get a call from noridian explaining what is wrong with our application. Not just one thing. Noridian doesn’t seem to have a copy of our business license from five years ago. We have to put the personal Ptan on page xgyb-14. They want details about the nursing home. Do I do home visits?

The noridian person explains that our application has actually been wrong for five years, but now they are getting audited so they have to get everything cleaned up.

So THEY have KNOWN it was wrong for five years, but held my payments since July, while they try to get their act together and tell me what the hell is wrong with it?

I want to be paid INTEREST for all the time I have spent on the phone and redoing the cryptic application.

And many thanks to my congresswoman, for keeping my clinic open.

I took the picture at the Kinetic Sculpture Festival here in September. The outfits make more sense than dealing with noridian, that’s for sure….

first posted on everything2.com on 11/30/15

by

Adverse Childhood Experiences 8: Social cues

I am thinking about social cues for people with high Adverse Childhood Experience scores. With crisis brain wiring the response to social cues may be very different than what is considered the acceptable “norm”.

I always miss the cue when someone says “see you later”. I think “When?” Then I realize it’s a social comment and they do not in fact plan to see me later. I have a moment of disappointment. I do the same thing when someone says, “Let’s get together for dinner.” or “Let’s have coffee some time!” or “I will call you back!” or “Why don’t you come to our cabin some day?” Yes, I think, when?

And then I think “Liar.”

So I fail social cues….. or do I? Maybe I am not responding to the “correct” or “conventional” or “nice” social cues.

My father drank too much and especially while I was in high school and college. And my mother would enable and cover up and pretend nothing was happening. Children in this situation, which is way too common, develop special skills.

My sister was three years younger. As adults we discussed the stages of drinking and which one we hated most. We would both walk in the house from school with trepidation. In the door and almost feeling the air: what is happening? Am I safe? Do I need to hide? How dangerous is it? How much will it hurt?

I walked in once during high school and missed the cue. I was thinking about something. I thought my father was asleep in the kitchen. I went in to get something. I was very quiet so as not to wake him. I made a cup of tea.

He was not asleep, or else he woke up. And it was the worst stage, or the one I hated most.
Not physical violence. But he started talking. One of things he said was “You can tell me anything.” Now, he meant it. But he was crying by then and I knew I did not want to tell him anything and all I wanted was desperately to leave the room. And neither my sister or my mother was home. Finally I was crying too, because I said “I just want to go read my book.” and he was more crushed and maudlin and emotional and crying. And I tore out of the room and up to my room, as my mother walked in.

I did not cry much. Ever.

I refused to talk to my mother about it.

The next day she said to me, “Your father told me that you were talking about Lamont.” Lamont Cranston was a very beloved cat, The Shadow, who was missing now. Dead, we thought.

I said nothing. Because we had not talked about Lamont. So either my father was lying or else he’d had a blackout, didn’t remember and was making shit up. And if I told my mother the truth, she would back him and deny what I said or make it into a joke.

The stages my sister and I identified were:
1. sober
2. a little bit
3. goofy/silly/makes no sense
4. crying
5. asleep

We were ok with 2 and 5. I don’t think we saw 1 for years. We disliked 3 intensely, especially in public and especially when our mother was doing a cover up dance. And 4 we hated.
And yet I loved my parents and mostly miss them now that they are gone. Except when I remember things like this.

So, what is the point?

I miss “social cues” because that is NOT what the crisis brain, the ACE score brain, pays attention to. I am paying attention to far more intuitive things: body language. Whether what the person is saying matches what I know about them and what they have done in the past. I am looking for whether this person is telling me the truth.

I don’t trust instantly. Why would I?

I said to a counselor once that reading the “cloud” around the person was terribly useful in medicine but made me a social misfit. “I don’t know how to turn it off.” I said. She grimaced and said, “Why do you think I went into counseling?” She said, “I can’t turn it off either but I have learned to ignore it during social situations.” I was in my forties before I realized that there are people who don’t sense this cloud, who trust people until the person is dishonest, who understand that it is just fine to say “Let’s get together.” and not mean it.

Because actually, when someone says “I’ll see you later.” and they don’t mean it, they are saying an untruth. They are not planning to see me later. They don’t mean it. And my brain automatically files that under evidence that this person is not trustworthy. To them it is a social cue that is polite. To some of us, it is clearly something that is not actually true. I pick up on a cloud of social cues, but not the ones that are acceptable or conventional. And I am not the only one.

my sister on the left and me on the right, in the 1960s

by

Rural medicine crisis: Job offers

One of the signs that we are entering a worse crisis for rural medicine is job offers.

I am starting to keep the email job offers: so far the record is from Texas, a random out of the blue job offer for $500,000 yearly.

One half million dollars for a Family Practice job. I won’t take it. I like my clinic and anyhow, the pace they would set me to work is burning out physicians. They are quitting, though some die instead. A recent article said that this year a physician poll reports the number at burnout this year has risen from 40% to 50%.The job offers roll in. I get phone calls, emails, mailing and now my cat is getting rural family medicine job offers. Really. Desperate times.

Years ago I read that only 30% of family practice doctors are willing to take a rural job and that only 30% of those are willing to do obstetrics in a rural area. I did obstetrics as part of my practice from 1996 to 2009. I stopped when I opened my own practice, because the malpractice price tag is three times as much and my rural hospital was grumpy at me. Starting in my third year of medical school, I did deliveries for 19 years. During my nine years here, the cesarean sections were done by the general surgeons and we did not have an OB-gyn. I called Swedish Hospital Perinatology when I needed help. I got to know them well enough that if I had someone in preterm labor I would call and find out who was on call BEFORE I chose a medicine, because I knew which perinatologist liked terbutaline and which one would rather I would skip it and use procardia. They were fighting out the research: I didn’t know who was right, but it is a huge benefit to have your consultant be happy with your choice if you have to lifeflight the patient by helicopter at 3 am. With a 25 bed rural hospital, we try not to deliver a baby under 35 weeks, and it’s better to fly the baby in mother if you can’t stop the labor.

Back to the numbers: so 33 out of 100 family practice doctors will take a rural job and only 11 of those are willing to do obstetrics. Our first day of medical school, the faculty said, “Shake hands with the person on your right. Shake hands with the person on your left. At least one of the three of you will be sued for malpractice in your career.” Oh, goody, let’s start training with paranoia. Or is it just being realistic and prepared?

I worked for five years between college and medical school and took the GREs first. I thought I was going to get a PhD. However, I did not want to write a thesis and did not want to be one of three world experts in anything. I had a friend who was one of three world experts in honeybee behavior. I asked what happened when they got together. “We argue.” he said. I also did not want to publish or perish, tenure was becoming more of a problem and anyhow, I did not want to be tied to a university. I got a job working as a lab tech in the National Cancer Institute at NIH in Bethesda. Two years there gave me my answer: primary care is the ultimate generalist. I could work anywhere in the world, in a city, in a small town, and there is endless lifelong learning. I took the MCATs and got into medical school, determined to do primary care.

Back to the job offers: 450K for Iowa. 310K, 350K, signing bonus, paid move, 6 weeks “off” (As far as I can tell it’s always unpaid leave. No sick leave, no paid holidays, no paid leave at all. Do factor that in.)Production bonus. No call or phone calls only. Near a city! In a city! Cheap houses! Excellent schools for your children and 6 stellar golf courses! FP job in Texas, 315K, 4 day work week, signing bonus, loan forgiveness!

The most that I’ve made in a year, I think, is less than half the listed average income for family doctors, though that has risen by nearly 1/3 in the last ten years. And that was enough and I didn’t see enough of my two children and the next year I worked less. I have never made the “MGMA average” for what a family doctor makes and it was more than ten years ago. I am below average in income but I think I am above average in personal happiness and way below average in burn out! I made way less last year, because I was out sick for 6 months. Ok, I lost money. However, my clinic still nearly covered expenses and stayed open, with no provider from early June to November 15, thanks to my receptionist, my patients, the PA who stepped in in November and the other independent practitioners in town. The hospital system refused to help except that they took over my 18 patients on controlled substances… after I threatened to complain to the state that they were refusing care. How nice.

I have an old house and old cars. I have a son finishing college and a daughter about to start. More money to retirement seems like a good idea. I now have 25 years as a member of the American Academy of Family Practice and I am an “old” doctor, because I didn’t retire at 50. I told a younger partner at the hospital that I was deliberately being “below average” because I was going for a career with longevity and wanted to avoid burning out. He left town last year….

From the American Academy of Family Practice paper http://www.aafp.org/about/policies/all/rural-practice-paper.html : family practice providers are 15% of physicians in the US, but do 23% of the visits each year. And in rural areas about 42%. “In the U.S. as a whole there is 1 Primary Care physician per 1300 persons while in rural areas the ratio is 1 Primary Care physician per 1910 persons and 1 Family Physician per 2940 persons. In the most rural counties, those with a community of at least 2500 people but no town over 20,000, close to 30,000 additional Family Physicians are needed to achieve the recommended 1:1200 ratio.” I have patients driving from over an hour away because it takes months on the waiting list to see a primary care doctor in their area, and now I am seeing veterans too, because we are more than 40 miles by road from the nearest VA hospital.

This article:Β  http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/ makes me laugh. The student says that 90% of family practice visits are probably coughs and colds. Uh, I would say that less than 5% of mine are. Half of my patients are over 65 and what I do is care for chronic disease with some acute disease thrown in. Diabetes, hypertension, coronary artery disease, rheumatoid arthritis, stage III renal failure, opiate overuse syndrome, depression, PTSD, and the average patient has 4-5 chronic diseases, not one. So the complicated ones have 9 chronic diseases. If they have walking pneumonia and diabetes and are 80, what was their last creatinine so I can adjust the antibiotic dose for their stage three renal failure? My oldest current patient is 98, has diabetes and still is out haying…. rural medicine is never ever boring and some days I think, oh, I would pay to see a simple cold. In the last two months one patient had a four vessel bypass, two have hepatitis C, one has hepatitis B and last month I found one with pertussis: whooping cough. And one has to go to the Big City to see the gynecologist-oncologist….

Rural family medicine is the ultimate generalist. I have to know a little bit of everything and know when to call and ask questions and who to call. Once I had an obstetrics patient with severe and confusing back pain after an epidural. I knew it was something peculiar because we could barely control it with opiates and her back exam was fine. I started calling specialists: ob-gyn didn’t know. The nurse anesthetist. My local internist. An orthopedist. A neurologist, the closest one 90 miles away. Then I got it: I called an anesthesiologist in Denver, 250 miles from where I was. He said it was an inflammatory reaction to the epidural medicine and to give her steroids, which would fix it. It did… but it was my being sure that I had something different on my hands and the stubbornness to keep calling until someone knew the answer….

A friend from college got a PhD in genetics and then went to medical school at the same time as I did. We talked when we picked our specialties. She chose pathology. I chose Family Practice. “Not Family Practice!” she said. “Why not?” I asked. “You can’t know everything!” she said. I said, “Well, no one knows everything. Put three top specialists in a room and they argue about the research. The trick is knowing what you know and what you don’t know.”

We need more primary care physicians and more rural family doctors. And it’s only getting worse.

http://www.aafp.org/about/policies/all/rural-practice-paper.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071163/
http://healthleadersmedia.com/content/COM-208773/Physicians-Offer-Insights-on-Practicing-Rural-Medicine.html
http://www.siumed.edu/academy/jc_articles/Distlehorst_0410.pdf
http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/
https://www.aamc.org/newsroom/newsreleases/358410/20131024.html
https://www.washingtonpost.com/news/to-your-health/wp/2014/05/22/how-many-patients-should-your-doctor-see-each-day/
This blog post helped inspire this article: https://theridiculousmrsh.wordpress.com/2015/11/03/why-i-hope-my-doctor-is-off-having-a-cup-of-tea-as-seen-on-the-huffington-post-yup-actual-huffpost/

The picture is some of the madashell doctors on our first trip stumping for single payer health care in 2009.

by

Spare the rod

You say you want a partner to join in work or love
It bothers me to hear you say those words
sand inside my clothes

a partner is someone that you respect and listen to
I hear a disconnect between your words and plan
someone to improve upon

You’ve chosen your next target for this thoughtfully
I can see that your plan would work quite well
practical and logical

I do not think that he will bend to your desire
Carved and polished, obedient as wood
sanded to a shine

Earthquakes and fire shake and forge our world
I stand in awe before the forces on us all
that make us grow

There is only one that you should try to change
The stubborn foe that eyes you when you shave
will keep you busy

And God will gild the lily

I took the photo in 2012 from the Kai Tai Lagoon in one of our rare snows. It looks like a magic castle on a hill to me.
I published this on everything.com today too.

by

Guide to determining if you are constantly being mauled by bears

This is for Ronovan’s weekly haiku prompt. The words this week are guide and mad.

Beloved guide me
through red mad anger open
heart to shores of love

The picture is my son and daughter on the shore of Lake Crescent, Washington in 2004. We stopped driving for a rest. My son has just skipped a rock and I love the curve of his body and physical joy expressed. He’s trying to influence what the rock does with his body language. How can we all stay that fluid and joyful?

I stole the title from here: http://everything2.com/title/Guide+to+determining+if+you+are+constantly+being+mauled+by+bears

by

Veracity

V for veracity in the Blogging from A to Z challenge.

I am thinking about veracity and my father. Veracity is truth, faithfulness, accuracy, correctness.

I was frustrated about how someone was reacting to something and asked my father about it.

My father said, “Most people don’t want reality.”

“What do you mean?” I said.

“Most people work hard to avoid reality. They have a set of ideas and a world view and they get upset if something does not fit in it or if it is questioned.”

I have been thinking about a song that I learned as a kid. It falls into one of the “Dead Girl” songs, as my sister called them. I think of them as teaching songs. I am taking guitar lessons and my teacher says that he won’t sing those songs.

I will. I like the dark songs. And I am very ambivalent about this song:

There was a wee cooper wha lived in Fife,
Nickety, nackety, noo, noo, noo;
And he had married a gentle wife,
Hey, willy, wallacky, ho John Dougle
Alane, quo rushity roo, roo, roo.

She would na bake nor would she brew,
For spilin’ o’ her comely hue.

she would na caird nor would she spin,
For shamin’ o’ her gentle kin.

The cooper has gone to his wool pack,
And he’s laid a sheep’s skin on his wife’s back.

“I’ll no be shamin’ your gentle kin,
But I will skelp my ain sheepskin.”

“O I will bake and I will brew,
And think nae mair o’ my comely hue.”

“O I will wash and I will spin,
And think nae mair o’ my gentle kin.”

A’ ye what hae gotten a gentle wife,
Send ye for the wee cooper o’ Fife.

This is Child Ballad number 277 and has been recorded by Burl Ives and others.

Ambivalence. It’s a song about wife beating, I don’t approve. But it’s also a song about surviving. A cooper builds barrels. The job division was that the wife would bake and brew, card wool and spin. However, this wife is “gentle” as in gentleman, of “good birth” and rejects the work as beneath her. Does she expect to be served? In the stories of happily ever after, we are happy when the poor underdog poor person wins the love and admiration of the other person, but we don’t see what happens when they go home. In Disney movies, the girls are poor and win a prince. Or Aladdin becomes a prince.

Skelp is defined as “hit, beat, slap”. The song doesn’t say whether the cooper does beat the sheepskin tied to his wife’s back or only threatens to do so.

I love word play so I like the “alane, quo rushity roo, roo, roo.” Nonsense words delight me aside from the topic of the song and I like the tune.

I think that our culture has years of men dominating women and expecting women to obey. I dislike that intensely. At the same time, I don’t like it when people won’t contribute and when they avoid work, so I also have some sympathy for the wee cooper. And our culture spends too much time thinking “happily ever after”, trying to find just the right person. We do not enough time actually asking each other what “happily ever after” would look like. And anyhow, it doesn’t exist. For richer, for poorer, in sickness and health: that is the veracity. We all will have challenges and everyone will have illness and hopefully good times too.

I am thinking of the many people lost in the recent earthquake. Lost: killed suddenly. Enjoy each day and be kind to yourself and others. We never know when grief will strike.

by

Phoenix Rising

P for Phoenix, for the Blogging from A to Z Challenge. This post is for Amanuensis Sobriquet-Reverie. Her poem today “Burn the witch” brings up present and past difficult memories. Here is the poem I wrote about it in 2003.

Phoenix Rising

Set a torch to me
Why don’t you?

It’s not the tearing sound of fabric
A small rip
And now a tear
That I feel

It’s the torch

I’ve been here before
A job where the idealistic came
As moths to the flame
Self-immolation
Because they had ideals

I watched and burned and rose

It’s the torch
The flames that rise
As the witch is burned
Tilts back her head
In ecstasy and knowledge
Eager to learn what she can
From these burning brands

In the burning we learn
In pain we learn
If we can remain open
Ashes fall to the ground
Buckets of water
Wash any remains to grey mud
Gone, punished
Relief for the frightened
An example has been set

No but what stirs at night
Moon or none
What rises from the mud
The ashes
Takes form
Takes flight
Laughing

Set a torch to me
Why don’t you?
And see what is created

a local bookstore
previously published on everything2.com

by

Move

M is for Move in the Blogging from A to Z Challenge

Move

Blessings on you

Take care of my heart

I know I’ve left it with someone kind

You don’t have to do anything with it

No giri

No obligation

You can set it anywhere

In a corner where it gets dusty

And covered with sawdust

Under the couch

In the woods

The kids can play catch with it

I don’t care

I am armored up

I am ready

I am ready to move

In the direction that I have chosen

Stand aside, please

I don’t want anyone to be hurt

Power up, armour, sheilds

I pick my sword back up

Obeisance to the Beloved

I move

38314-m

by

Hurt and healing

H is for healing and hurt in the Blogging from A to Z. I mentioned dreaming of monsters in my Gift post, and this is the poem about that dream. It is hard work to heal.

Advice to Micheal

Neverland
Is such an ironic name
Can’t they hear?
Can’t they think?
The land where boys never grew up
The Lost Boys

And you
Are not molesting
Boys
You are
Searching
When I heard
About your childhood
I knew
They were wrong
They’ve missed the boat

You sang
Like an angel
And the world
Stole your childhood

Hotel rooms
With older brothers
Sex
Drugs
Alcohol
Money
Chaos
And you must have been
So frightened
Lost
Pressure to sing
As the star

Locked your core self away
To keep it safe

My childhood
Was scary too

I started my search
With a dream
Of a dark hole
From which came the sound
Of monsters
Howling

I was scared

I went to the hole
anyway
scared
of the howling

The hole was dark
And roots stuck out of the side
Like reaching fingers

I got a flashlight
And looked

It wasn’t as deep
As I thought
And the roots worked as
A ladder

I climbed down
Into the hole

I found three monsters
Howling

Baby monsters

I put them in my pack
And carried them up
Into the light

They howled

I bathed them
And diapered them
And fed them
And rocked them

They howled
They didn’t know what to do
When taken care of

I named them
Fear
Grief
Shame

At last they stopped howling
And sat
Warm
Wrapped in blankets
Ugly
Sullen
Lower lips thrust out

And I found a shrink
To talk about my dream
And to help heal the monsters
That I had rescued

We always have more
Work to do
But now I have a little girl
Inside me
Who came to greet me
When I had healed the monsters
Enough
She is beautiful

You won’t find
The Lost Boy
That you are looking for
Outside you
He is inside
He is innocent
And beautiful

You may have to face
The monsters
Of your childhood
To reach him
Yours was worse than mine
I’m sorry

You may have to face
How much people you loved
Hurt you
Even though they loved you
I’m sorry

Find help
And rescue
The Lost Boy
And joy

Good luck.

Poem written August 10, 2005. Previously published on everything2.com.

by

Angel

I am in the April Blogging from A to Z Challenge and I am already late… that is, I did not post yesterday, my “A” day. I didn’t know what my theme for the month would be this morning. This morning, I am reading Micheal A. Singer’s The Untethered Soul and I found what I would be writing about.

I have written about my inner angel and devil before. That voice inside that talks all the time and makes judgements and gets excited about everything. Mr. Singer says that that voice is not us. That voice is like a roommate who talks constantly and is very dramatic. He talks about stepping back and watching that roommate and listening. If the roommate were a real person, we would cut them off. “Stop talking!” we would yell. But they won’t and they wouldn’t and we cannot get away.

So when that voice gets really irritating I call on my angel and devil to take over. They argue. The angel always says “Forgive.” The devil wants to whack the angel over the head with a hammer to shut them up. The angel forgives the devil for being nasty. The devil gets even more nasty and sarcastic and then I start laughing. The inner angel and inner devil are so over the top. Perhaps someone stepped on my toe and it hurt. The devil suggests what to say to them, where they should go, how to punish them. The devil is unreasonable and suggests punishments that are so far beyond the original insult that the angel appears and says, “Stop that. You aren’t being nice.” The devil swears. The angel says, “Well, your toe doesn’t hurt anymore does it and anyhow someone pushed the person who stepped on your toe so it wasn’t their fault and why did you come to a crowded concert if you can’t tolerate your toe being stepped on?” Then they may continue to fight for a while. At the concert I am laughing, inappropriately, because of the inner dialogue.

Today I want to thank that inner angel for all the times that she or he has calmed me down. Has stepped forward and said, “Stop reacting.” For being loving all the time.

Thank you, angel.

And here are synchronized swimmers, practicing before a competition. In the competition, they will not wear the swim cap or the goggles. This is a lift, remember, where none of them touch the bottom of the pool. It is all supported by the girls swimming. This is a team of eight, so four are supporting from under water, holding their breath. Trust and teamwork.