I voted

…after I spent about three hours going through paper and throwing it out… ok, like a total numbskull I mislaid my ballot. Have you mislaid your ballot? FIND IT! VOTE!

” …that government of the people, by the people, for the people, shall not perish from the earth.

When I went across the country as a Mad as Hell Doctor in 2009, we talked to people everywhere. I joined the group in Seattle. I had never met any of them and had only heard about them two weeks before. But we were on the road, talking about health care, talking about single payer healthcare, talking about Medicare for All.

Some people said, “I don’t want the government in healthcare.”

We would ask, “Are you against medicare?” “No!” “Medicaid?” “No!” “Active duty military health care?” “No! We must take care of our active duty!” “Veterans?”  “No! They have earned it!”

…but those are all administered by the government. More than half of health care in the US. So let’s go forward: let’s all join together and have Medicare for ALL! And if you don’t agree… so you don’t think you should vote? Hmmm, I am wrestling my conscience here….

We need one system, without 20 cents of every insurance paid dollar going to health insurance profit and advertising and refusing care and building 500++ websites that really, I do not have time to learn and that change all the time anyhow. How about ONE website? How about ONE set of rules? We are losing doctors. It’s not just me worrying: it’s in the latest issue of the American Academy of Family Practice.

Vote. For your health and for your neighbor’s health.

____________________________________________

Physicians for a National Healthcare Progam: http://pnhp.org/

Healthcare Now: https://www.healthcare-now.org/

I can’t credit the photograph, because I don’t remember who took it…. or if it was with my camera or phone or someone else’s! But thank you, whoever you are!

stay or go?

For the Ragtag Daily Prompt: migration.

I took this on a beach walk with my aunt and uncle on Sunday. They were visiting from Virginia. They’ve flown back now.

This is taken with the zoom all the way out. I recognized the great blue heron, but in the first picture I can’t tell what the geese are. With a face in profile in this second photograph it’s clear that they are Canada geese.

The geese are migrating but the great blue heron stays and winters over. Most of our hummingbirds migrate, but the Anna’s can winter over. And I have been asked: stay or go? My landlord asks if I will renew my lease for my clinic in February.

I reply that I am waiting on the US Congress. My clinic is more than half medicare patients. 48% are over age 65. Congress is discussing paying a flat fee for medicare visits: about $43.00 dollars. At the moment I do not see how I could keep my small solo clinic open if that goes through. Stay or go? It is stressful. I want to stay. But I may have to migrate like the geese….

I think a frightening number of physicians would either migrate or stop taking medicare patients, opt out of medicare, if Congress passes this bill. The AAFP is fighting it. I contact Congress too, but I am tired of fighting for single payer, medicare for all. Patients spend more on their dogs’ health than their own. How can I do good care and feel valued for $43.00 per clinic visit?

I thought the thing most likely to close my clinic is the cost of my own health insurance. But Congress may close me down by dropping my payments from 48% of what I bill, to less than 25%. Yet they say they want good care for our country….

Message me if you contact Congress to say do not do this. And thank you so much if you do.

The proposal for medicare changes is 1472 pages. So I am supposed to find time to read that and comment on it in addition to taking care of my patients? What sort of insanity is this?

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/

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.

does chronic pain kill you?

Another writer sent me this story, saying that chronic pain killed Prince, not an overdose.

http://www.rawstory.com/2016/05/prince-did-not-die-from-pain-pills-he-died-from-chronic-pain/

My response is complex.

1. Is chronic pain an “illness” in it’s own right?

My answer is yes and no. It’s complicated and our understanding is evolving. Right now I think of chronic pain as a switch in the brain that gets thrown. It can be thrown by adverse childhood experiences, by infection, by trauma or war or abuse, by too much stress… or a combination of any of these.

2. Why a switch in the brain?

In fibromyalgia patients we can’t find much on physical exam, except that the pain seems out of proportion to the exam. Ditto with chronic fatigue, reflex sympathetic dystrophy, TMJ, etc. However, now we can image the brain with a functional MRI and watch which parts are lighting up and how much. A study of “normal” and fibromyalgia patients involved a standardized pain stimulus: a thumbscrew. (Kinky, right?) The normal patients said the pain stimulus was 3-4 out of 10 and their brains lit up a certain amount. The fibromyalgia patients said the same pain stimulus was 7-8 out of 10 and the pain parts of the brain lit up MORE corresponding to their pain level. So they are not lying… and it IS in their heads. Sort of. We aren’t sure whether the muscle is yelling more than normal or whether the brain is hypersensitive or both. My guess would be both.

And I think this is an adaptation. It is to get us to rest, heal, calm down, introspect, stop being type A, etc. Boy, do we suck at it. Though recently I had a person in clinic who said what their body wanted to do was nothing. They just wanted to lie around. I said, well, ok, so when can you do that? They did, for two weeks, at the holidays. And my patient said, “One day I had a cup of tea and a book and the cat on my lap and the dog at my feet. I realized that my adrenaline system was turning off and I felt calm and relaxed. Healed.” Back at work the person cannot always maintain it but is getting better at it.

3. What does this have to do with Prince?

The problem is that for 20 years we treated chronic pain with opiates. Unfortunately on continuous opiates, the brain cells change in many people and “down-regulate” the opiate receptors. Less receptors, the pain rises. The person needs more opiate. The brain removes more receptors. So two myths: one that if you have chronic pain and take medicine as directed, you can’t get addicted. Only dependent. Since that is a myth, the DSM-V has combined addiction and dependence into one diagnosis: opioid overuse syndrome. It is a spectrum, not two separate responses.

The second myth is that if you give enough opioid, it will help the pain. Well, no. UW Pain and Addiction Clinic says that on average pain is reduced about 30% by opiods, whatever the dose. And high doses start causing some weird  hyperalgesias. I’ve weaned two people from over 100mg methadone daily down to 20-30mg. It took two years. They felt better on the lower dose after they got through withdrawal symptoms and a short term increase in the pain receptors complaining at them. And they are much less likely to overdose and die.

Page two here http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf discusses current knowledge about opioids.

4. So like, Prince?

He may have died from a combination of fatigue and sedating drugs. If you get enough sedating drugs, then you stop breathing. Opioids are the biggest offenders combined with alcohol or sleep medicine like ambien or benzodiazepines like valium or ativan or alprazolam or muscle relaxants like methacarbomal or a combination of all of the above. I am a strict physician about urine drugs screens and I do the dip in clinic in front of the person. Way too often, the person does not tell me about the alprazolam or whatever until I am holding the dip over the cup…. and that’s when they tell me. They got it from the ER or a friend or two years ago or … took their dog’s. Really.

He may have died from influenza, if he had it, with sedating drugs. Bad influenza causes lung tissue swelling and can mess up your oxygenation. Your heart has to take up the slack and go faster. If you are trying to work and your heart rate is well above normal, it’s exhausting. It can kill you.

He may have died from overwork, another infection, sedating medicines…. but not directly from chronic pain. Chronic pain slows us but I do not think it kills us*. What kills us is trying to treat it with a pill instead of resting and doing gentle exercise and saying: What does my body want?

 

5. Overdose?

Also, are we talking about an accidental overdose? Are we talking about drug abuse? Are we talking about accidental death or suicide or do we as a society think that addiction deserves overdose death but a person taking medicine for chronic pain is a tragedy? Aren’t we a bit judgemental?

Prince may have taken a pain pill as directed but taken it with too many other controlled substances or with alcohol or while sick and exhausted. Overdose means too high a dose. If it was two percocets, alcohol, flu and xanax…. it could be an accidental poisoning.

6. Are you sure?

No. Medicine changes. Our understanding of the brain changes. Science is about change and deepening understanding. We are barely getting started on the brain and I would say that we are in preschool there.

 

 

*Stress alone can cause heart attacks and sudden death:    http://www.health.harvard.edu/blog/stress-cardiomyopathy-a-different-kind-of-heart-attack-201509038239

The photograph is from a week ago, part of my Maxfield Parish cloud series, zoomed way in to the mountains across the water.

 

fraud in medicine: cow thymus guinea pig

We are making a change in clinic. We ask all new patients to bring ALL the pills they take. Prescription, vitamin, supplement. Most of them don’t. So now we are telling patients that they need to bring all pills or they will be rescheduled.

I want to know what my patients are taking. My town is a delightful spectrum mix from very conservative to very liberal and some libertarians thrown in. But I look at the ingredients of the bottles.

With prescription medicines, people will say “I am on metoprolol.”

“What strength?” I say, “And is it the short acting, middle or long acting?”

Some patients: “Uh…. it’s blue. It’s a small blue round pill.”

Eye rolling would be unprofessional. I pick the lowest dose and type in “unsure dose”. “Bring it next time.”

I examine vitamin bottles. Some contain multiple herbs as well as vitamins. Most people don’t seem aware of this. Sometimes people have four different vitamins with vitamin A in them. “The fat soluble vitamins A, D, E and K can build up in your tissues and people have managed to kill themselves. I would recommend you take less then you are taking.” And then there are the high dose vitamins: one with 3999% of the recommended daily allowance of vitamin A. Hello. Why is this being sold? I guess people have the right to take things that can kill them. But I wish they wouldn’t.

Supplements. I read the ingredients. One ingredient is cow thymus. “This has cow thymus in it.” I say. Medicine seems a bit vague on what the thymus does, though it is involved with myasthenia gravis: http://www.mayoclinic.org/diseases-conditions/myasthenia-gravis/multimedia/thymus-gland/img-20007802

“Oh.” says my patient.

“I am very unenthusiastic about taking cow thymus.” I say. “Unless you are working with a naturopath who has prescribed it for a compelling reason. Who prescribed it?”

“Uh, it’s not prescribed. It’s made by a good company.”

Right. Like I trust corporations. Scamming thieves and liars. Sell anything that isn’t nailed down in pill form. Including cow thymus.

My medical philosophy is as few pills as possible. Prescription, vitamin or supplement. Eat food, exercise, make friends, work well, be kind to yourself and others and avoid pills unless necessary. We don’t know how cow thymus and metoprolol interact. The FDA considers supplements to be natural, like a carrot. A pill is not a carrot. It doesn’t grow on a tree or in the ground. It has to be made by people. The supplement companies do not have to do any testing for medical safety and efficacy and I frankly hate the pills with multiple herbs in them. They have to use ingredients that are “generally recognized as safe” which is pretty lukewarm: http://www.fda.gov/Food/IngredientsPackagingLabeling/GRAS/. Also, kidney failure is on the rise from too many pills. Everything is metabolized by either the kidneys or the liver and kidney failure is in the top ten causes of death in the US.

And I don’t want to be a guinea pig. I don’t want to be the personal home chemistry trial of cow thymus plus metoprolol. No way. And I will bet that you don’t want to be a personal home guinea pig either.

I took the photograph with a zoom lens looking down from the dock in Port Townsend Bay in 2014.

Dear Mr. Donald Trump

Two weeks ago I sent this letter to Mr. Trump and all of the presidential candidates. To date I have gotten a form letter from Mrs. Hilary Clinton.

Dear Mr. Donald Trump and all Presidential candidates:

Mr. Trump, I am a rural family practice physician, a woman, who owns and runs my own medical clinic. I take care of patients from age zero to 104. Currently my oldest is 98. I take medicare and most insurances, but not medicaid.

I am running into legal immorality across the board from health insurance corporations that are maximizing profits at the expense of my health care dollar, our taxes and my patients. I would like your advice.

For example, the Veterans Hospital contacted me in May of 2015 and asked me to accept Veterans Choice patients, veterans who live more than 40 miles from the nearest VA Hospital. I accepted. I have 6 veteran patients, who are very complicated. To date I have not been paid for one visit. Now, before you say this is the fault of our government, it isn’t. It is the private for profit government contractor Triwest who is not paying me. They have my notes and we have followed their instructions on how to submit bills. Would you advise me to drop these patients?

For example, my father died in 2014. I called the oxygen company to pick up 6 tanks of oxygen. Then I found 8 more. I gently inquired why he had 14 tanks. The company said that his medical orders said that he should wear it continuously, so they delivered it. “Medicare paid for it.” they said. Ah. Well, I kept the other 8 tanks, because it is my and my father’s oxygen in those tanks: the company can have the tanks back when they are empty.

For example, the head of the sleep apnea supply company came to see me. He said, “You are getting in the way of your patients getting needed equipment.” I said, “Really? How?” “You only allowed a refill of one of the 8 necessary pieces of CPAP tubing instead of signing off on the whole group so we can fill as needed.” “Ah.” I said, “Actually my patients are tired of you mailing them 8 pieces of plastic that are filling up their closets and they don’t want extra plastic crap.” He mails it at the interval allowed by medicare, never mind whether the patient wants or needs it.

For example, I called a patient’s insurance to get a prior authorization last week for a limited sinus CT. They no longer do prior authorizations. They will decide whether to cover the CT scan once they read my notes. I asked if there was ANY way to see if it would be approved. They offered to let me send a letter to a PO Box in Wisconsin. My patient was sick, Mr. Trump. What do you suggest the patient and I do?

This is all legal. But it is not moral. So, Mr. Trump, where do you stand? Is our country’s highest value free enterprise and profit at any cost, no matter how many of our seniors are legally ripped off? Or do we have morals that health care and our elderly are important and need to be protected from legal but predatory businesses.

Please let me know, Mr. Trump. I would rather stick with my small clinic in the United States. At this point I would be financially and emotionally better off working as a temporary doctor internationally. I am sure that there is immorality internationally, but I will be less ashamed when it is not MY country.

Thank you.