the virtue of the disconnect

the virtue of the disconnect
learnt early
as a child

they say we are broken
wired wrong
enduring horror

he wakes at night
sleeps lightly

what was your childhood like?
how did you sleep?

it was not safe
we had to get up
leave in the night
gunshots

you survived your childhood

yes, I did

sleeping lightly saved you

yes, it did

you could rewire that
it takes a lot of time
to change the childhood wiring

or you could just
be ok

with sleeping lightly

blues too

For the Ragtag Daily Prompt: brilliance. The brilliance of the sky reflecting in the water.

blues

blues, Beloved

I am so blue, Beloved
about the things I can’t heal
about the people I can’t heal
about the relationships I can’t heal

I take my own advice
and walk after clinic
and the beauty of your sky, Beloved
heals me
lifts me
sensory

I am with the trees
the sky
the dirt
the clouds
the water

water water water
blue in the evening light

we only see the surface
of the water
not what is underneath
it reflects the sky
the light
the clouds

people are like water

we only see the surface
and see ourselves reflected back

my office manager came from hotels

this is so much harder, she says

and I say yes
because we see the depths

this person is behaving badly
yelling on the phone
calling crying yelling

but we both know
how much they are suffering
how much they want help
how they won’t listen or accept help

they want what they want

these people are breaking down
in the holidays stressed

I just long for rest Beloved

blues

doctor’s orders

For the Ragtag Daily Prompt: recommend.

doctor’s orders

I recommend a daily walk

no earbuds
no headphones

listen to the wind
to the trees
to the birds
to the traffic
to the city
or the country

feel the ground
the pebbles
the sidewalk
the dirt
the grass
the wind
the sun
the rain
the cold
the crunch
of snow or ice

look at trees
weeds
birds
dogs
people
sidewalks
cracks
water
snow

smell cold
snow
rain
sun
sand
sidewalks
grass

taste the wind
a snowflake
a leaf
ice

touch the earth

and let the rest go

USPSTF

USPSTF is the United States Preventative Services Task Force.

Here: https://www.uspreventiveservicestaskforce.org/.

This is a site I often use and frequently show to patients. For further reading….that is, if they want to know more about a topic. There is a nice two minute video about the Task Force right now, saying that it’s a volunteer organization that started 30 years ago, to review research about preventative care, agree on a recommendation and publish that recommendation.

Before they publish or update a recommendation, they ask for public comments and expert comments.

I have great respect for the USPSTF. Let’s take breast cancer screening. The current recommendation is here: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening1. There was a big furor when this came out, because the recommendation is for biennial mammograms. Every other year, not every year. The USPSTF went through reams of data and papers and said that they could discern no difference between yearly and every other year screens in normal risk patients. The screening recommendations are different for people with abnormal BRCA1 and BRCA2 genes.

So who yelled about that recommendation? Radiologists for one. Now, there is a financial incentive on their part to have women get the mammograms yearly. The American Cancer Society was annoyed and the Susan B. Komen Foundation too. But the USPSTF stand their ground. The guidelines get updated in a 5-10 year cycle.

Reasons that I like the guidelines:

1. They are online. My patients can look at them too.
2. They make recommendations for screening by age groups.
3. They rate their recommendation: A, B or C level evidence or I for Insufficient Evidence.
4. You can read the fine print. They put the article with all the detail and all the references on the website. The weight of evidence is apparent.
5. They say “We don’t know.” when there is insufficient evidence.
6. The site is pretty easy to use.

I have to weigh evidence in medicine. A functional medicine “study” that is not a randomized double blind clinical trial and that only has 20 patients is really more of a case report. Hey, we tried this supplement and they liked it. The recent study about alcohol from Europe with 599,912 patients has a lot more weight. The Women’s Health Initiative had 28,000 women in the estrogen/progesterone arm, and 21,000 in the estrogen only/had a hysterectomy arm. Length of study, design, all of these are important.

There is a recent headline about a study saying that coronary calcium scores have now had one study where they were useful. That is a study. The guideline from the USPSTF is here: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cardiovascular-disease-screening-using-nontraditional-risk-assessment. The guideline says “insufficient evidence” and that’s what I tell patients who ask for it. I offer referral to a cardiologist to discuss it, but I am reluctant to do a test where I really don’t know what to do with the results. I pay very close attention to the guidelines and they are always changing. They have the strongest and least biased (by money and greed) evidence that I can find. And patients can read them too, which is wonderful.

Even though the USPSTF says that there is insufficient evidence for mammograms after age 75, we can still do them. That is, medicare will keep covering them. Some people keep doing them, some don’t. I discuss guidelines, but I will support the person continuing the care if that is what they want and they are informed. People are infinitely variable in their choices and logic.