Category Archives: grief

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bye bye doctors

stop this healthcare bill… until there is transparency… or this will get worse.

 

I am grieving, watching doctors leave.

I have been in my rural county, 27,000 people, for 17 years.

Doctors are leaving. Wake up, United States.

The trend when I got here was that we had 14 primary care doctors and 5 midlevels. For years, we lost one primary care doctor a year. I would grieve and it would mean more work, every year. We would get a new doctor, but often there would be a gap… I made up a game to help cope with grieving. I call it “Local Doctor Survivor”. I would bet on the next doctor to leave and also on their trajectory. One of three: nice doctor, angry doctor, doctor labeled nuts. Burn out.

But…in 2015 it jumped. Suddenly we had 3 primary care doctors and two midlevels leave. Uh-uh. One was a husband and wife, doctor and nurse practitioner. One switched to being a hospitalist. Another left. And another midlevel. By then, we still had 14 primary care doctors, but the number of midlevels, nurse practitioners and physicians assistants had risen to 12. Ok, 12 plus 14 is 26. One fifth left. That is a bad trend.

In 2016 another physicians assistant retired. One of the best. I stopped counting who was leaving. Until another doctor announced they were leaving in February 2017. One of the best. That doctor said that a 20 minute visit generates 1 hour of paperwork. If one works “full time” the quota of patients is 18 per day, 72 in the four day week, and that is 32 hours four days a week of 20 minute visits. Generating 72 additional hours paperwork. That is 104 hours a week. Unsustainable.

The 2016 salary information is out for primary care. The “median” family practice physician in the US makes $168,000. Ok. But every doctor given as an example works 60-70 hours a week. Maybe that salary is not as good as you think. Because they are quitting.

Our neurologist retired, in about 2010. I was bummed. The county north of us has 75,000 people. They had two neurologists. Both left in the last two years. The county south of us has 350,000 people. They had five neurologists. Two have left, including my current favorite. For the first time in 17 years I have a neurology referral refused: and not one, but two. Send them to the big city, says one. The other just says no.

I call ENT and he bemoans that now they are down to three in the county. Another left. Three there, one on the county north of me, great, we have 4 for 450,000 people.

I get a letter from one of the two neurosurgeons in Seattle that I like best. In 2016. He is leaving to go do medical administration in another country.

Our three counties are down three dermatologists. One sent a letter. “I am quitting on October 1, 2016, unless ICD-10 is cancelled.” ICD-10 is the new manual of diagnostic codes. It was not cancelled so that dermatologist quit. We have to code every diagnosis. ICD-9 had 14,000 codes. ICD-10 has 48,000. I am memorizing the new ones. I10 is hypertension. E11.65 is type II diabetes in poor control. I used to be able to write a prescription for diabetic supplies, lancets and glucose strips. Now I have to include the ICD-10 code on the prescription and often the pharmacy cites medicare and demands that I fax proof that I have seen the patient and that the patient does indeed need the prescription. I frankly have better use for my brain than memorizing the ICD-10 codes, but whatever.

Another clinic closed in the county north of us and our county. Then the main clinic closed in the county south of us. Within two weeks. 3500 patients needing primary care providers and refills and we can’t get old records because the rumor mill says it was a “hostile takeover”. That is, the person who owned the clinics quit paying the bills, so the electronic medical company won’t release the records. Great.

I have been absorbing about one new patient per day worked since March, but I am getting tired and will have to back off.

Meanwhile, our county hospital has been hiring specialists. Gynecology, new orthopedists, dermatology. Great, right? But currently most specialists won’t take a new patient without the patient having a primary care doctor. Why? Well, one of the new trends is that the specialist says the patient needs something but that I should order it. Yep. Had one of those yesterday. The specialist says I should order it. It’s a veteran. So I get to fill out the VA authorization paperwork with the ICD-10 codes and the CPT code for the study, fax that to the VA, call the patient and remind him to call triwest, because if the patient doesn’t call then triwest throws the authorization paperwork out. And the specialist makes more than 5 times the amount I do. Maybe I should retrain. I am a specialist: family practice, three year residency, board certified, board eligible. But….. I have little value in the United States.

We are seeing Veterans in spite of the extra paperwork. Triwest is sending us 5 from Whidby Island. They have to take a ferry to see me. Because no one on Whidby is taking veterans. My receptionist complains to triwest about all the doctors leaving the Olympic Peninsula.

“No,” says the triwest person. “Not just the Olympic Peninsula. The whole west coast of the US.”

 

http://www.aafp.org/news/government-medicine/20170620senatespeakout.html

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Dream log: June 20, 2017

I am with my father and my sister. My mother is not around. I am not sure if she’s gone or dead. Dead, I think.

My father has gone off. My sister is 3 or 4 and I am 6 or 7. I am taking care of her. We are at a park and I am trying to get food. It is Thanksgiving. It is not cold, it’s warm. There are large family groups at picnic tables.

My technique is to move in on a family group. We play near them and I listen for adult names. We play close enough that I can hear but not close enough to impinge on the group. When they start to clean up and take things to the cars, I am ready. I slip in and hold my hands out for a bowl. The adult looks at me. “Aunt Norma’s.” I say confidently, because I know which bowl belongs to each adult. And which bowl I want. The adult hands me the bowl. They can’t remember which kid I am, but I know Aunt Norma’s name….I head confidently with the bowl towards the cars and quickly slide it under my loose sweatshirt. I bypass the cars and head around to my sister.

Now the game changes a little. We have a couple bowls so she guards them. I work the next table alone and score a left over turkey.

The problem now is that we cannot carry it all to the car in one trip. I debate about safety. We are living in the car. I tell my sister to stay with the rest of the food and I leave her, carrying the turkey. It’s still light and there are still a lot of people around. She is sitting on the curb, bowls behind her, between two family groups. I will get the turkey to the car and then run back to her. The two of us can carry the rest of the food in one trip. Then we will have food for a while. She should be safe.

I wake up.

I took the photograph within the last month. What and where is it?

 

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screen door

For Thursday doors. This is one of the cabins that my family owns at Lake Matinenda. I don’t think anyone has stayed in it since my sister died in 2012. That summer my daughter and I went and tried to clean some. There were too many things that were out where the mice could get them. We bought plastic containers and crated things up. We took all the beer bottles in the boat to the car and 17 miles to town to recycle them. We took loads of mouse nested clothes and shoes to the dump. We took a guitar that belonged to my sister home to my niece.

We were too raw to make decisions, to take the clothes and wash them and give them to a charity. It is time to do that.

A door into memory and how much my daughter helped, with no complaint.

 

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prayers for children

This is my daughter, five years ago, at Lake Matinenda in Ontario. I cried when I read about the baby thrown from the London fire.

Prayers for the children in the London fire and their parents and grandparents. Prayers for the refugee’s children, that they are not lost and drowned. Prayers for the Congresspeople shot yesterday and their families and friends.

Prayers for all the children in the world.

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damage

This is not about one patient. It is about many. I have permission from the person I gave a copy to: one of many.

what do you say
to the person
with the terrible childhood
with addiction and chaos
and suicide attempts and hospitals
and that was the parents
that they ran away from

and then numbed themselves
in addiction for years
multidrug and chaos
and now stable
working their 12 steps

and grieving
their lost years
and their behavior
unforgiven, it takes time
to build trust after
thirty years of damage

and grieving
the next generation
following the same
path and feeling helpless
to stop them
and guilt for their
contribution

it is not a matter
of a pill
of a diagnosis

the simplicity of stopping
of getting clean
joy and pride
yes

and then the hard work
of grieving
begins

 

____________________________________________________________________________________________

I took the photograph at the Renwick Gallery.

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yielding

Y for yielding in Blogging from A to Z.

Again, the definition changes, from Webster 1913 to the present.

Webster 1913: yielding

Inclined to give way, or comply; flexible; compliant; accommodating; as, a yielding temper.

Yielding and paying Law, the initial words of that clause in leases in which the rent to be paid by the lessee is mentioned and reserved. Burrill.

Syn. — Obsequious; attentive. — Yielding, Obsequious, Attentive. In many cases a man may be attentive or yielding in a high degree without any sacrifice of his dignity; but he who is obsequious seeks to gain favor by excessive and mean compliances for some selfish end.

— Yield”ing*ly, adv. — Yield”ing*ness, n.

Dictionary.com is different:

adjective

1. inclined to give in; submissive; compliant:
a timid, yielding man.

2. tending to give way, especially under pressure; flexible; supple; pliable:
a yielding mattress.

3. (of a crop, soil, etc.) producing a yield; productive.

Crop yields are important! But is compliance or giving in, a feeling of yielding, something I am comfortable with? What about yielding to love or to grief or to joy?

Today’s poem:

yield

I am yielding to my family
to no more contact

though I think they see me
as stubborn angry argumentative

they do not love me as I am
they want a different person

who acceeds and yields to their ideals
I am the villain who won’t yield

and yet I yield
I send them love

I send them joy and peace
one said if you make me choose

I won’t choose you
pressure, sorrow, grief

acceptance: I will miss them
I do not know if they

miss me

 

I took the photograph at the Women’s March in Port Townsend. When should we yield? When should we fight? When should we reach out for mutual understanding?

 

 

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vulnerable

V is for vulnerable, in Virtues and views, Blogging from A to Z.

Is feeling vulnerable a virtue or a vice?

I don’t think feeling vulnerable is either a virtue or a vice. It’s a feeling. It is a feeling that our society puts pressure on adults, particularly males, not to feel. Or not to admit.

I read Robert Johnson, PhD, Owning our own shadow. He asks what three aspects of ourselves we are most proud of. For me, at that time, the triad was toughness, smarts and independent. He says that the opposite, or shadow, of that triad, is what we are most afraid of….

….oh, and he had me there. I look in my mirror and see someone smart, tough, independent, and terrified of being vulnerable.

I am much less terrified now. I am a physician: everyone is sick sometimes, vulnerable sometimes, everyone does dumb things sometimes, and dependence will come as well as death. I needed to bring that fear out of the shadow and make friends with it. Bringing those shadows forward is hard work! I don’t want to! But I can and I like to work and I am good at working. Small steps daily on a path with love and thought and care…..

Dictionary.com vulnerable

adjective

1. capable of or susceptible to being wounded or hurt, as by a weapon:
a vulnerable part of the body.

2. open to moral attack, criticism, temptation, etc.:
an argument vulnerable to refutation; He is vulnerable to bribery.

3. (of a place) open to assault; difficult to defend:
a vulnerable bridge.

4. Bridge. having won one of the games of a rubber.

So we ALL fall under the first definition! ALL OF US!

Our culture derides and conflates vulnerability with weakness sometimes. Don’t let it. Stand up. Speak out. Do not let fear stop us….

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new growth

I’ve been thinking about the A to Z challenge again. I did it last year, with 7 sins and friends. I wrote about an emotion each day…. and I planned to do it this year starting with the 7 virtues. Bet you can’t name as many virtues as sins…. though I don’t think any of the emotions are sins. They are part of us. They are part of the way we respond to the world and survive. We have to learn to pay attention to them and not label any of them as negative or bad. We cannot excise grief or fear or anger from our psyche and remain human. Instead we need to learn to be curious about each emotion….

…..and there has been a shift in my life, three parts all shifting at once, this week. It is very odd to have all three go at once. I may leave the virtues until next year, because this sudden freedom is strange, peculiar, unfamiliar…. I need to expand in it and explore it….

New growth….