Category Archives: change

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The isolated working

I ran my own small clinic from 2010 to 2022, working somewhere else, got Covid, was on oxygen for a year and a half, did some healing and then came back to work.

There has been a culture change in medicine that feels very strange to me. I did not notice it because I was in a solo clinic and not “part of the system”.

All the doctors, providers, are more isolated. I got a compliment yesterday when I was doing a “warm hand off” of the most sick or complicated patients, three new diabetics, a person with cancer, a person with a genetic heart problem. The doctor who I was handing off to is in the same clinic but we have barely talked since May. I don’t know her at all. She complimented me on excellent care “and calling specialists”.

I thought, huh. But I think that is a dinosaur doctor thing. I think mostly people communicate through the electronic medical record email, send messages about patients. For the decade that I was solo, I had to call other specialists because I was on a different electronic medical record. The email didn’t connect. The hospital reluctantly gave me a “link” to their system, but it was only a link to look. I could not write or send anything.

About two months ago I got an echocardiogram result. I read it and thought, ok, it’s not normal but what does it mean? Outflow obstruction by the thickened heart wall. Hmm. I called cardiology and spoke to the cardiologist who read it. He sounded surprised and said, “Idiopathic hypertrophic cardiomyopathy, most likely. It’s a classic echo.” “So, what do I do?” “Send him to me.” “Anything that I should change meanwhile?” “Yes,” says the cardiologist. He had me stop one medicine and start another. “No vasodilators and the beta blocker slowing the heart rate should help decrease the outflow obstruction.” “Got it.” I said. He also gave me two more tests to order.

I referred the patient to cardiology but it was a month before he got in. The two tests were done and they ordered more. If the diagnosis is correct, he’ll be sent to a special clinic in Denver. I called my patient while we were waiting for the cardiology visit. The medicine change had not made much difference as far as he could tell.

I was also told when I got here that I would never get a local nephrologist to see a patient, they were two busy. However, I have called two nephrologists about two patients and both took the patient and again, gave me instructions.

Two specialties have been very difficult to contact: orthopedics and gastroenterology. I have no idea why they are so difficult.

I can see that email feels faster. But there is no human contact, asking follow up questions is difficult, I don’t get that bit of further helpful education: this is what you do next. I have learned so much over the years by touching base with specialists. Once I fussed at a patient to go to hematology oncology about their high platelet count. The patient didn’t want to. He came back and said, “Apparently I have this newly found genetic problem. They put me on two medicines, not expensive. And I feel better than I have in 20 years.” I asked the oncologist about it the next time I called. He lit up, excited, and told me about the JAK-2 mutation. It is so exciting to learn about new areas in medicine and my patient says, “I have to thank you for pushing me to see the oncologist. I feel so much better.” Wow and cool.

Clinic feels like I am mostly isolated, a silo, an island, rarely talk to the other physicians unless I go to find them. I think hospital administrations like this, keeping the physicians in line by having their schedule be so packed that they almost never talk to each other. What a good way to keep physicians from interfering in the money making production! Ugh, I think it is quite horrible and unhealthy for the providers and for our countries medical system in the long run. I was seriously less lonely in a solo clinic.

The prognosis for our current medical system is very poor. The patients say to me, “Why do my doctors keep leaving?” They aren’t attached, they are isolated, I don’t think the physicians know what they are missing. Colleagues. Not silos.

For the Ragtag Daily Prompt: prognosis.

The photograph is from the Fruita Fall Festival.

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Bolster meaning

It did not even occur to me that yesterday’s dream could be taken as complaints about patients! That was not my meaning!

I wrote the dream out because I wanted to know what it was trying to tell me. And I look at it from the perspective of all the people in the dream being aspects of myself.

So who is the whiny guy (me) who won’t cooperate with authority (me) and who wants attention and is difficult? That’s not a very nice aspect of myself!

First of all, he reminds me of my father. My father really did not like authority and did not like most men. When I was quite small, I announced that he would have to die first, because he couldn’t live without my mother, but she could live without him. I was wrong as well as being an awkward child. My father’s dislike of authority interfered with his employment and he was mostly underemployed. He finished a Master’s in Mathematics, but never wrote the thesis for his PhD. I asked him why once and he said, “I was bored.” I don’t know how much alcohol interfered with his working.

I am not brilliant with authority either, though I am trying. I notice systems and often annoy authority by asking why something is run a certain (foolish and unproductive) way. I used to study whatever system I was in and then say, “Here, I’ve thought up a solution for this problem.” Then I would get in trouble for suggesting that there was a problem and I would be the problem. I learned to go to authority first and ask, “So is this (huge problem) a problem? I find it difficult. What is your advice?” Priming the pump, so to speak.

As a temp, the authority problem is weirder. I am an outsider, short term, no one really has to be nice to me. That fast trip home and back made me realize that I am lonelier in a group clinic than I was in a solo clinic. In my solo clinic there was me, my receptionist and the patients. In this group clinic I have less people to talk to and it is lonely. My problem, not theirs. They are about to move me to another clinic and I will see what approach I can take to this. The system might have a Balint Group or I may be able to start one.

What about the frozen looking spouse? Ha, I think that’s the part of me that is trying to keep my mouth shut with authority. The kids? Some days I want to pull the system apart and fix it, but I am not in authority to do that here. The grumpy nurse? I am running behind and I can’t fix everyone. Some people don’t want to be fixed, including me.

I could go home and try another place. However, I think that the cracks in the US medical system are in the whole system. As a country, we built this. I hope that I see single payer healthcare in my lifetime, but I may not. And Martha is right too: I thought that this place was doing better handling a chronic illness than where I worked in 2021, but they aren’t, really. They apply a formula, but the patients don’t get much out of it. They just get shuffled in once every three months. I did upset that apple cart by spending more time with those people and talking to them, but I do not know what the next physician will do. Sigh. The patients are already my patients and are saying goodbye.

For the Ragtag Daily Prompt: meaning.

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Mind

Facing a wall or lying in bed
breathe slow: four seconds in
one two three four
four seconds out
one two three four
keeping count

or facing a wall sitting
on a zafu, bell rings to start
how can forty minutes be so long?
fall asleep and body weaves
waking me up OH don’t hit the wall
adrenaline then slithering down
towards sleep again

zen mind, blank mind?
my mind wanders off again and again
what is for dinner? grocery list?
that annoying thing or person
at school or work
the mind busy as a squirrel
burying nuts and digging them back up

bring the mind back again
again again again
to the breath the wall letting go
of this well trodden mind trail
only to have the mind wander off
down another: this with briars
and falling into a pond
that has ice and cold

back shake like a dog
shake it off
focus on the breath the wall again
vivid multicolor cats
with paisley and stripes and spots
there is the BELL
forty minutes

Bow to the wall
and stretch
get up
ready zafu for the next time
meditation
mind

_____________________

Written today for the Ragtag Daily Prompt: blank.

The translation that I originally learned is here.

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the pale reflections of our bitter selves

they are neglected, you know, by most
the worse self, the worst self, the dark
the impulse to yank the moon from the sky
when she slides down the stair, to see who’s there

there are few poems written to the dark
impulses, the demons, the underside of our hopes
and dreams, the nastiness, the grief, the anger
we are kept in the dungeons below the basement

below the belt we band together huddle
in a pile of claws and unfeathered wings and teeth
wishing for a blanket, to be held, rocked
loved, wishing for the mothers who left us

the fathers who denied us, pushed us away
so that we knew and know what to hide
what to deny, what part of ourselves to kill
we try and try but few do

and then they are mourned, people say
they don’t understand but ask the demons below
and oh, they do, they do! maybe the next plane
will be kinder and love the demons

the bitter self, the dark self,
that longs so badly to be loved
that longs forever to be loved
that is not loved this round

this round

written 11/24/2023

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Wild

I keep wondering at the stubborn part of me that will not let go.
 That wants to reconcile with all, no matter what they’ve done.
 I go inside, deep and deeper, in the depths all is slow.
 That part is the holy part that longs for the One.
 I have been told to let go of things, forget, no more longing.
 But the longing is a sacred place, a longing for the Beloved.
 I think that excising it would be a horrid evil wronging.
 Handle gently, with care, with love, and gently gloved.
 I meet someone who says, “You are very in touch with your inner child.”
 I know it’s not a compliment, I smile and pay little mind.
 My Child is my connection to the Beloved, fierce and mild.
 Jealous judging rolls right off, people can be unkind.
 I won’t excise the holy core, the Beloved inner child.
 I feel the Beloved’s laughing play and joy, heart running wild.

_________________

For the Ragtag Daily Prompt: realize.

https://www.playingforchange.com/videos/words-of-wonder-get-up-stand-up-song-around-the-world

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Sisyphus

Sometimes clinic feels a bit like Sisyphus must feel. Rolling the stone of illness up the hill but it is eternally rolling back down. I can’t stop it. People age and people die and otherwise there would be no room for young ones.

The last two weeks of clinic has worn me out a bit. A friend says that I take too much of it home, worrying about people. How to let go of this?

I make connections in clinic. Not all the time. Sometimes I fail. I made a connection with more than one person with diabetes this week, but one was funny. The connection is that he mentioned that he is an elk hunter. Oh, and flies to California to fish and has a very lot of fish. I said that I’ve had elk and like it. That was when the connection engaged: he was very pleased that I am not horrified by hunting. Hunting elk is not at all easy or cheap and cleaning the animal and carrying it out, well. He is coming back about his diabetes and left cheerful.

If I go home trailing those connections and spend my time worrying about this people, I’ll wear out. I don’t want pneumonia number five. So how do I connect but let it go when I go home?

I will think of the connection as much smaller than the boulder that Sisyphus deals will. Not a boulder. A small piece of the rock. I can suggest how the person can lighten the load a little. Then I must stand aside and let them go. They have to decide what to do about their health. It is between them and the Beloved, they can try what I say or not.

Now it is not a boulder that I am trying to keep from rolling down a mountain. Each person has their own mountain to climb in their life, their own habits and histories, good or bad, trailing them like Marley’s Ghost in A Christmas Carol. I can suggest a tool to loosen a link of diabetes, or a slightly different trail up the mountain. Then it is up to them. I can’t carry them and should not carry them. Maybe they are approaching a patch of scree and I can suggest an easier or safer path. And then stand aside, stand down, let the people go.

Now I am not pushing a huge rock. I am standing on my own mountain, quiet, and looking at the path behind. I am resting a little and on my own path. I don’t know what will be around the next bend in the path. But I love the mountain and the forests and the birds and the ocean. All of it.

Thank you, oh Best Beloved.

For the Ragtag Daily Prompt: olympics!

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G6PD deficiency and diabetes

Today I follow an online trail to this article on diabetes from Nature Medicine here.

It is talking about a genetic variant that is found in people with African-American heritage called G6PDdef. This genetic pattern makes the HgbA1C test inaccurate. It will look low and “in control” even when blood sugars are high. Since the blood sugars are NOT in control, complications from diabetes can happen: damage to vision, to kidneys, to nerves in the hands and feet.

I have been reading articles about current and changing guidelines about diabetes. The current guidelines say that checking blood sugars at home doesn’t make a difference. I REALLY disagree with this and at the same time, I don’t think that physicians are approaching blood sugars in a practical manner.

I saw a man recently who is diagnosed with “insulin resistance”. His HgbA1C is in between 5.6 and 6.0. Normal is 4.5 to 5.6. Over 6.5 is diabetes. He has prediabetes. He has not checked blood sugars at all, but he is on metformin.

There is evidence that metformin is helpful, and still, I think it is putting the cart before the horse. I ask my people to go buy an over the counter glucometer. Ask for the one that has cheap strips, 6 for a dollar instead of a dollar apiece. Then we go over the normal and abnormal blood sugar ranges and I ask them to start checking blood sugars. If I give them a medicine right away, they don’t learn how to control their blood sugar with diet. ALL of my patients can figure out how to bring their blood sugars down with diet. If we can’t get to a good range, then we will add metformin. I do explain that the guidelines say use a medicine right away, but I ask, “Would you like to see if you can control your blood sugars with diet?” The answer is overwhelmingly “YES!” I have never had someone say no. If we do not give them the chance and explain the goals, why would they even try?

Also, I read the dietician handouts for diabetes yesterday and I am not satisfied. I do not think they explain carbohydrates well. Foods have fats, proteins, and carbohydrates, and anything that isn’t fat or protein has carbohydrates. I think of carbohydrates as a line, from ones with high fiber that do not send the blood sugar up fast, to ones that shoot it way high. At the low end is kale and lettuce and chard and celery. Then the green and yellow and red vegetables that are not sweet. Then beets and sweet peas. Next come the fruits, from blueberries up to much sweeter ones. Fruits overlap with grains: bread and pasta and potatoes and rice. The whole grains have more fiber and are slower to digest. Candy then sweet drinks (sodas are evil) and sugar.

Sugar has 15 grams of carbohydrate in a tablespoon. Kale has 7 grams of carbohydrate in a cup. That’s a pretty huge difference. A small apple has about 15 grams of carbohydrate and a large one 30 grams. Read labels for grains. There is a lot of carbohydrate in a small amount. The issue with fruit juice is that most of the fiber is gone, so the sugars are broken down and absorbed much faster. A 12 oz coke has 32 grams of carbohydrate and a Starbucks mocha has 62! I quit drinking the latter when I looked it up.

Most people with diabetes are supposed to stay at 30 grams of carbohydrate per meal, or 45 if it is a big person or if someone is doing heavy labor. Snacks are 15 grams.

Avocados are weird. They have about 17 grams of carbohydrate in a whole one, but they also have a lot of fat. They do have a lot of fiber, which surprises me.

Diet control takes a combination of paying attention to what is on the plate and serving amounts. Three servings of pasta is not going to work, unless you are out fighting forest fires or are on the swim team. Fire fighters are allotted 6000 calories a day, but most of us do not get that much exercise.

At the same time that articles are telling me that home blood sugars are not useful with a glucometer, everyone is pushing the continuous glucose monitors. I think we like technology. And other articles say that diabetes can be reversed with major lifestyle changes.

Articles: about not using home glucose checks, here. Starting metformin, here. Starting with one of the newer medicines, here.

I think people feel a lot more successful if they get a glucometer and can bring their blood sugar down by messing about with diet. I tell them to check after what they think is a “good” meal and after a “bad” one. How much difference is there? Contrast that with being handed a pill to control it, while someone talks about diet and says all the same stuff that we’ve heard for years. Nearly all of my people want to avoid more pills and are willing to try a glucometer to see if they can avoid a pill. People who have been on diabetes medicine for a while are less willing to try, but sometimes they do too. And sometimes they are surprised that some meals do not do good things for their blood sugar.

This is all type II diabetes. For type I, we have to have insulin. If type II has been out of control for a long time, sometimes those people have to have insulin too. Right now insurances will usually cover continuous glucose monitors for people with diabetes who are on insulin, both type I and II. I do hope that they really make a huge difference for those people!

The spectrum from the low carbohydrate vegetable, the green and yellow and orange ones, up to the really high simple sugar ones is also called the glycemic index. There are lists of low to high glycemic index foods. Perhaps some people with diabetes find that helpful, but I think it’s simpler to say, ok, the stuff that doesn’t taste sweet will send the blood sugar up less. Also, since we are all genetically different and then our gut bacteria and microbiome are all different, it is individualized care to say how does this person at this time respond to this food? We change over time!

There are other examples of the HgbA1C not working to track diabetes. A resident and I looked over a person with diabetes and spherocytosis. The HgbA1C was nearly normal but the blood sugars were in the 300 range. Spherocytosis is a genetic blood cell abnormality, and the red blood cells don’t live as long. People with a past bone marrow transplant also have red cells that live for a shorter time. The G6PD deficiency is thought to help people survive malaria, so persists in the population, like sickle cell anemia. Isn’t genetics fascinating?

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Tough cat

Sol Duc is quite a cat. The other morning I let her into the fenced back yard. I went back in to get my tea.

There is a knock at the front door. I open it and there is Sol Duc. “Meow!” which I hear as “Mom, I’m not supposed to be in front of the house without you.”

She comes in and I take my tea to the back. Oh.

Yes, I see the problem. She went into the neighbor’s yard and then around to the front. But she didn’t run off, she knocked. Apparently the storm was pretty hard on the fence.

This morning, after two days of rain, there were lots of small frogs singing to the sunrise in the man made run off space across the street. There is about a foot of water in it and the small frogs were all singing to their true loves. They continued to sing as the sun rose. Guess they better make hay while the pond is present, or something like that.

Sol Duc is a tough cat and smart. I think she still misses Elwha too, especially when I am at work, but she is careful not to run off.

For the Ragtag Daily Prompt: tough.

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Sky

The sky is bigger here than in Washington, at least, it seems bigger than on the Olympic Peninsula. It’s the lack of trees. Yes, there are mesas, but they are on the edges of Grand Valley and have very minimal foothills and then just go UP. I am enjoying the amazing cloud formations here. Maybe it’s also that often the clouds at home feel like they are two feet above the roof instead of way up in the sky.

Cee is getting better, so Cee, this sky is for you!

Yesterday we had an amazing thunderstorm with heavy rain and hail and water pouring under the front door of the clinic. The sidewalk must be tilted the wrong way. There were flood warnings and I waited until it calmed down a bit before driving home.

I like the sky, weather I am in Port Townsend or here. (Yes, wordplay on purpose).

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Lie low and flow

We have fight or flight for the sympathetic nervous system state, when we are ramped up, aggressive, go getters, all that stuff. We need a term for the parasympathetic nervous system state, the relaxed one. So far I’ve come up with lie low and flow. Other suggestions? I welcome them! We need more lie low and flow and glow and say no and ho, ho, ho in the world. What puts you in that state? Knitting? Stupid cat videos? Bugs Bunny? A bubblebath? Watching toddlers? What makes you laugh and yawn and relax and lets all the tension flow out and sink or float away?

In clinic I am seeing a wide age range. Most of the younger ones, say, under 60, look a bit shell shocked. I think this is still from the pandemic and wars and political nastiness. The over 60 crowd seems to not care as much. They’ve been through it, they know people die, they know bad stuff happens.

A friend and I were talking about pandemics and he pointed out that HIV and AIDS was a pandemic too. So we are on track for two pandemics per century. The younger folk do not remember the HIV and AIDS pandemic and how frightening it was. Right before that started, some doctors proclaimed that infectious disease had been conquered by medicine. Um, RONG RONG RONG! Boy did they eat THOSE words. And early in that pandemic, no one knew what to believe, what was happening, how to stay safe, and the communication from the medical establishment changed very fast. I wonder if the people who were young adults and older in the 1980s were less surprised by the Covid-19 Pandemic and all the rumors and confusion. Yep, seen it before.

I am not sure how to help the younger shell shocked looking folks. Colorado is a bit tough and manly and consequently there is not a huge amount of resources for emotional health. Yesterday I asked if we have anyone who does neuropsychiatric testing and the answer I got was “I don’t know.” I will dig around today but did not find it on the internet. I have found neuropsych testing hugely helpful for traumatic brain injuries, post brain surgery, and to sort out unusual learning and memory styles. One woman had a brain tumor removed. Her memory was affected. She could remember things that she wrote down and read, but not things that she only heard. No one had given her the report to read. They only told her, so she did not remember it. At least, that was the story. I gave her the report and said, “Read it. And tell your family. And if you are on the phone, take notes.”

Ok, now I should get ready for work, though I want to lie low and watch a silly cat video.

For the Ragtag Daily Prompt: yawn.