I am trying to catch that distant line of light on the horizon as the light recedes….
….I am so grateful that the basic healthcare requirements will not be dismantled, joy!
….and now on the horizon I hope for vision and light and single payer, medicare for all. My Veteran patients this week are afraid, that Veterans Choice will be taken down. I am afraid too….and still, I hope for vision and light.
Nearing the end of a beach walk with my daughter at Fort Worden, the Strait to the west had a line of silver at the horizon. Gorgeous in all weather….
The vote today by Congress would remove the minimum services that insurances must offer in the US. Steps backwards, where cancer screening or hospital services or life flights or pregancy may not be covered. VOTE NO!!!!
And we still need medicare for all, single payer, so that 20% of every healthcare dollar is not going to insurance company profit…..Can’t they see?
January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.
Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….
Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.
So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.
A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.
I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.
Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.
If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.
If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.
Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65
We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.
And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.
https://www.uspreventiveservicestaskforce.org/
guidelines: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
http://jamanetwork.com/journals/jama/fullarticle/1791497
Here is the two page hypertension JNC 8 algorithm: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House: https://www.guideline.gov/
This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..
I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….
Pain is not a vital sign anymore, as I described in yesterday’s post. I wrote this poem in 2006, about painΒ being the fifth vital sign. I disagreed.
Vital signs II
Pain
Is now a vital sign
On a scale of 1:10
What is your pain?
The nurses document
Every shift
Why isn’t joy
a vital sign?
In the hospital
we do see joy
and pain
I want feeling cared for
to be a vital sign
My initial thought
is that it isn’t
because we can’t treat it
But that isn’t true
I have been brainwashed
We can’t treat it
with drugs
We measure pain
and are told to treat it
helpful pamphlets
sponsored by the pharmaceutical companies
have articles
from experts
Pain is under treated
by primary care
in the hospital
and there are all
these helpful medicines
I find
in my practice
that much of the pain
I see
cannot be treated
with narcotics
and responds better
to my ear
To have someone
really listen
and be curious
and be present
when the person
speaks
If feeling cared for
were a vital sign
imagine
Some people
I think
have almost never felt cared for
in their lives
They might say
I feel cared for 2 on a scale of 10
And what could the nurses do?
No pills to fix the problem
But perhaps
if that question
were followed by another
Is there anything we can do
to make you feel more cared for?
I wonder
if asking the question
is all we need
first draft 5/20/06
I took the photograph Friday afternoon from the beach: two fronts were meeting. What is that like in the sky? Do they fight or welcome each other?
A recent article in the Family Practice News says that a survey of 225 physicians reveals that 33% of them think that the opioid crisis in the US is caused by over prescribing opioids. 24% said aggressive patient drug seeking and 18% said it is due to drug dealers. How quickly things change.
In 1996 pain was declared the fifth vital sign, after temperature,Β pulse (heart rate), respiration rate and blood pressure. I disagreed with it because it focused on pain, by telling the nurses in the hospital and the outpatient providers to always to ask about pain. I thought it would be better to focus on level of comfort than pain. I thought we were using opioids far too freely and I thought that patients were getting addicted. The pain specialists said that we had to treat pain, and we were given very few tools other than opioids. Primary care providers were told that they could be sued for too much or too little pain medicine.
I also disagreed with it because pain is NOT a vital sign. That is, the level of pain does not correlate with illness. If a person has a high fever of 104 I am sure they are sick, a fast or very slow heart rate, a blood pressure too high or two low, they are breathing too fast: these are vital signs. They often correlate to illness and help us decide if this is outpatient, urgent or emergent. But pain does not. A chronic pain patient may have a pain level of 8/10 and yet not be an emergency or in a life-threatening state at all. That does not mean that they are lying or that we don’t wish to help with pain.
In June, 2016, the American Medical Association recommended dropping pain as a vital sign. https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign. The Joint Commission for Hospital Accreditation dropped pain as a vital sign in August, 2016. https://www.jointcommission.org/joint_commission_statement_on_pain_management/
Why? Not only were people getting addicted to opiates, but they were and are dying of unintentional overdoses: sedation from opiates with alcohol, with anxiety medicines such as benzodiazepines, with soma, with sleep medicines such as ambien and zolpidem. If the person is sedated enough, they stop breathing and die. The CDC declared an epidemic of unintentional overdoses in 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm and said that more US citizens were dying of prescription medicines taken as instructed then from motor vehicle accidents and guns and illegal drugs.
So the poem below and a second poem I will post tomorrow reflect how I thought about pain as a vital sign. It is not a vital sign, because a high pain level does not tell me if the person is critically ill and may die. It does not correlate. Pain matters and we want to treat it, but the first responsibility is “do not harm”. Letting people get addicted and killing some is harm.
Also, opioids have limited effectivenessΒ and high risk for chronic pain. I have worked withΒ The University of Washington Pain and Addiction Clinic since 2010 via telemedicine. They say that average improvement of chronic pain with opioids is about 30%. Higher and higher doses do not help and increase the risk of overdose and death. And the risk of addiction.
I think of pain as information. Studies of fibromyalgia patients with functional MRI of the brain show that they are not lying about their pain. In a study normal and fibromyalgia patients were given the same pain stimulus on the hand. The normal patients said that they felt 3-4/10 pain. The fibromyalgia patients felt 7-8/10 pain with the same stimulus and the pain centers lit up correspondingly more in their brains. So they are not lying.
Why would opioids only lower chronic pain about 30% even with higher doses? The brain considers pain important information. We need to snatch our finger away from a flame, stop if we smash our toe, deal with a broken bone. I think of opioids like noise cancelling headphones. Say you are listening to music. You put on headphones/take round the clock opioids. Your brain automatically turns up the gain: the music volume or the pain sensors. Now it hurts again. You take more. The brain turns up the gain. Now: take the noise cancelling headphones off. The music/pain is too loud and it hurts! With music we can turn it down, but the brain cannot adjust the gain for pain quickly.
We do not understand the shift from acute pain to chronic pain, yet. The shift is in the brain. I think that we are too quick to mask and block pain rather than use the information. Now the recommendations for opioids are to only use them for 3-5 days for acute pain and injury. For years I have said with any opioid prescription: try not to take them around the clock and try to decrease the use as soon as possible. Some people get addicted. Be careful.
If we don’t hand people a pill for pain, what can we do? There are more and more therapies. Jon Kabot Zinn’s 30 years of studying mindfulness meditation is very important. His chronic pain classes reduce pain by an average of 50%: better than opiates. Pain and stress hormones drop by 50% in a study of a one hour massage. Massage, physical therapy, chiropracty and acupuncture: different people respond to different modalities. Above all, reassuring people that the level of pain in chronic pain does not correlate to the level of illness or ongoing damage. And pain is composed of at least three parts: the sharp nocioceptive pain, nerve pain (neuropathic) and emotional pain. We must address the emotional part too. We have no tool at this time to sort the pain into the three categories. My rule is that I always address all three. That does not mean every person needs a counselor or psychiatrist. It means that we must have time to discuss stress and discuss life events and check in about coping.
In the survey of 225 providers, 50% estimated that they prescribe opioids to fewer than 10% of their patients. 38% said less than half. 12% estimated that they prescribe opioids to more than half their patients. The survey included US primary care, emergency department and pain management physicians.
Handing people a pill is quicker. But we can do better and primary care must have the time to really help people with pain.
Vital Signs I
In the hospital now
I am told we have a new
Vital sign
Like blood pressure and pulse
We are to measure
Pain
And always treat it
Sometimes I wonder
Mr. X is in the ICU
I tell his family
He may die
On a scale of one to ten
What is his wife’s pain?
His daughter’s
We are not treating them
Only Mr. X
We try to suppress pain
Signals from our nerves
Physical pain is easier
I think of our great forests
We suppressed fire
And that was wrong
If fire is suppressed
Undergrowth builds up
Fuel levels rise
Fire comes
Rages out of control
All is destroyed
If fires burn
More naturally
More regularly
What is left?
At first it looks desolate
The tall trees are burnt
Around their bases
But they live
Adapted to the fire
Majestic pines
Revealed
Would our values were as clear
Some pines
Seeds
Pinecones
Will only germinate
In fire
When the undergrowth
Is cleared
Conditions are right
For new growth
Perhaps pain is our fire
Grief is our fire
If we block pain
Where does it go?
Does the fuel build?
I wonder if the tall pines
Fear fire
Would they avoid it
If they could
Perhaps suppression
Is not the answer
Perhaps we can change
Remain present
Acknowledge pain
As normal
As joy
Perhaps if I
Step into the fire
I can remain
Present
For you
And you will be
Less alone
Less afraid
I open my doors
Let the fire burn
poem written before 2009
CDC guidelines for treating chronic pain: https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf
My daughter and I marched yesterday.
She decided to come home from college for the weekend, planning to leave Saturday night. I decided not to go to the Seattle Womxn’s march, but do the Port Townsend one and asked her to join me.
We went out to breakfast and then to our small downtown. I no longer have television and look at news sites daily though a bit erratically, so neither of us had a pink hat. I wore my Mad As Hell Doctors t-shirt, my lab coat from working at the National Institutes of Health with the National Cancer Institute Patch, my Rotary name badge and pins gathered from going across the country trying to get medicare for all, single payer health care, from 2009 until now.
Four bus loads went from our county to the Seattle march. We heard that the Bainbridge ferry was FULL. That is, they couldn’t not take any more walk on people. Another thirty people or more flew to the Washington DC march. And in Port Townsend, my guess is that we still had 200-300 people, women, men and children, people in wheelchairs, babies, gay, lesbian, straight, bi, trans, that marched from a small park downtown to the Haller Fountain. Galetea, naked statue at the fountain, sported a pussy hat.
Our local organizer spoke and our House Representative, Derek Kilmer.
Older women spoke about demonstrating over and over in their lives. A friend of mine called me up to help her sing Holly Near’s Singing for Our Lives, making up new verses on the fly. They invited people to speak.
I spoke: “I am one of your local doctors. I want to be able to treat anyone who comes to my clinic. We are one nation: health care for all. No discrimination: medicare for all.”
Home then, and tired. My daughter has decided she wants to learn guitar, to play while people sing. I taught her basic chords and basic strumming. We sang Jamaica Farewell. She picks it up immediately, after all of those years of viola. And she will take one of my father’s guitars back to college.
And this is amazing: https://www.nytimes.com/interactive/2017/01/21/world/womens-march-pictures.html?smid=fb-share
Blessings all around.
Physicians for a National Health Care Program: http://www.pnhp.org/
I asked an older patient recently, “What is a bruise?”
She thought about it and said, “I don’t know.”
A bruise is blood, bleeding. Old blood changes color and is reabsorbed by the body as it heals. But where does that blood come from?
Any tissue in the body can bleed. Even a tooth, if broken into the center.
So what is bleeding for MOST bruises?
Muscle. Muscle, muscle, muscle, tendon, ligament, fascia, occasionally bone if broken and internal organs can bleed as well.
Somehow we entirely fail to teach this, at least in the US.
If you fall, or like my mountain biking daughter, hit something, your body will bleed. I tried to train the mountain bike team to carry an ace wrap and use it any time they hit something hard with an extremity. I pretty much failed. Why do I want an ace wrap and why use it immediately?
Trauma or hitting something hard causes bleeding. The more the muscle and tissue bleeds, the more swollen it gets. Usually the peak of bleeding and swelling is at about 48 hours after the injury. By then the body is sending immune system cells and repair cells to fix the trauma. It is swollen, red, hot, inflamed and painful! If we ace wrap our ankle or foot or elbow immediately, the bleeding stops faster. Wrap it, ice and elevate to keep the bleeding down. The torn muscles are held in their normal position, the bleeding stops more quickly, there is less swelling, less redness, inflammation and pain!
Our acronym is RICE:
Rest
Ice
Compression
Elevation
There are things that you can’t ace wrap: don’t ace wrap your neck or ribs and if it’s bad trauma to the head, neck, chest or abdomon, go to the emergency room! But even then, ice and compression help. First check airway, breathing and circulation, that the heart is beating if you happen on a trauma. But then try to use pressure on bleeding.
Do not put heat on a bruise for that first 48 hours. Why? It bleeds more and swells more. The exception may be if you do much more exercise than usual without a localized injury: hydrate, stay away from alcohol and a hot tub or hot bath may help. The hydration and hot water help the muscles relax and wash out the CK, creatine kinase, the protein from tiny muscle traumas that make us “stiff”.
The I in RICE used to mean ibuprofen as well. However, ibuprofen and aspirin and naprosyn are all blood thinners, so they may help with pain and inflammation, but may make the bruising worse. Acetominophen is not a blood thinner and also doesn’t do as much for inflammation, but it may be a better choice. It does help with pain.
In her third year of mountain bike racing, the Introverted Thinker had a quarter size bruise on her knee after a race.
“Are you going to do anything about that bruise?” I asked.
“No, it’s small.” she said.
“Ok.”
Two hours later: “Mom? Would you look at my knee?” Now the bruise is the size of an orange.
“Hmmm. What are you going to do about that?”
“I think I might ace wrap it and ice it and put it up for a while. Where is the ace wrap?”
Good plan. It didn’t get any bigger.
I see the handouts from the emergency room given for back pain and they are terribly misleading. It shows the spine and talks about the discs. 99% of the back pain I see is NOT a disc: it is the six layers of back muscles, and complex web of tendons, muscles and ligaments that hold the spine together and let us move in very complex ways. I pull my Netter Anatomy out daily in clinic and show people the six layers of back muscles.
What happens after a muscle is torn and bruised and bleeding? The muscle cramps up to stop the bleeding and attempt to keep from being torn more. No, I don’t like muscle relaxers much as medicines and they are useless long term. For sleep only right after injury. I am not talking about major trauma, but back pain and injuries.
If the muscle heals in the cramped position, it won’t work right any more. It can form scar tissue. It takes about six weeks for a muscle or ligament or tendon tear to heal and during that time we need to gently stretch the muscles without tearing them, so that they heal in the right position. Once they are healed in a scarred position, it’s more work to rehabilitate them, but it can be done. Physical therapy, massage therapy, chiropractor, acupuncture, but the most important work is done BY the patient, not TO them. I can’t fix it with pills. Yes, it is work.
You can bruise bone too. Ow. The surface of the bone is living cells and the bones are continually torn down by osteoclasts and rebuilt by osteoblasts. The bone can be bruised without breaking. Again, 6 weeks to heal, little kids faster and 90 year olds kind of slow.
Take care of your muscles, ligaments and tendons, and they will take care of you.
I took the photograph on the first Mad as Hell Doctors tour for health care for all in 2009. I will be marching again today:Β WE ARE ONE NATION! HEALTH CARE FOR ALL!Β NO DISCRIMINATION!Β MEDICARE FOR ALL!
Coming soon in the United States!
Aren’t you sick of the Affordable Care Act? aka Obamacare? Time for a new administration and time to get rid of Affordable Care. We don’t want that! Competition, Corporations and Profit First!
Call Mr. Future President Trump, call you congress persons, call your senator, call your representative, call your state ones. Stand up and be heard, US Citizens! Tell them you are all for the Unaffordable Health Care Act! We can kill more small businesses faster! We can make doctors and nurses quit by age 50! We can have more people turn to addictive drugs for numbing and comfort!
Come on, US Citizens! You voted! Now call! The Unaffordable Health Care Act! brought to you by an all conservative all corporate all discriminatory group of unbelievably rich congresspeople and your stinking rich and suing everyone future president.
Or you could say you want Medicare For All! Hey, one system, one set of rules, all US citizens have care, we could start small businesses, business might return to the US since they don’t have to pay more and MORE and MORE for health insurance, wages would go up instead of yearly decreases in health care coverage….nah, US Citizens, you wouldn’t want that, would you?
I don’t have any of THEM as patients. The unwashed masses. All of my patients are smart.
There aren’t any unwashed masses.
I have a gentleman who is overweight, obese, diabetes. He is not stupid. He is not unwashed. He is not exercising or controlling his blood sugar right now because the temperature is below freezing. He has a hole in his trailer floor and no heat. So he huddles under the electric blanket.
I have a gentlewoman, also diabetic. She too is not stupid. She is not unwashed. She lost her husband to cancer and then everything else and then was homeless for a period. She has a small house but she has no heat. She stays in bed to stay warm. Her contractor quit before he put in the furnace and he’s gone bankrupt. She is cold.
I have veterans. They are not stupid. They are not unwashed. One was homeless for a long period and pooled his resources with another to rent a section 8 house. I am so proud of them. They are having trouble living together, each would rather live alone. Only sometimes they would rather not be alone. It is hard.
I have a massage therapist. She started to train as a counselor. To be a counselor, she needs a certain number of supervised hours and was getting this through the county mental health. “I didn’t know.” she says. “It is taking twice as long as I thought because half the time they don’t show up. They don’t show up because they don’t have gas, they don’t have food, they have been evicted, their son is in jail, they are in jail. I had no idea. My massage clientele is so different, they pay. I thought poverty was in third world countries, but it is here, in my county. I didn’t know.”
I know the people who live in the woods. A schizophrenic who comes once a month for his shot. He was losing weight. “Why are you losing weight?” I demand. “I am only eating once a day.” he says. I nag him to go to the community meals. He is shy, he is afraid of people and he is hungry. He is not stupid. He is not unwashed.
I have opiate addicts. Six years ago one expressed concern. He is 6 foot 5 and big. “I am afraid of some of the other people. You shouldn’t be doing this! It’s too scary and dangerous!” My opiate addicts are not stupid. My opiate addicts are not unwashed. Sometimes they relapse. Sometimes they die, in their 50s, 40s, 30s, 20s.
One in six people in the US is below the poverty level. They are not stupid. They are not unwashed.
And when someone talks about the masses, the people, the stupid people, most people are stupid, the sheep….
….I am beyond angry….
….my heart hurts….
Poverty in the US: http://www.census.gov/newsroom/press-releases/2016/cb16-tps153.html.
More: http://www.census.gov/topics/income-poverty/poverty.html.
The examples are taken from 25 years of practice, details changed for hipaa, but I can list dozens at any one time. The photograph is during the sunset after clinic, when I walked down town, the view across the sound.
I have been writing posts about fraud in medicine: but I think I am using the wrong title. Instead it should be your health care dollar: how the US medical corporate system wastes your health care dollar.
Think about it. What do you want to spend that dollar on?
Do you want it to go to 1300 different insurance companies and their web sites, their advertising, their competition and their profit? Do you want your healthcare dollar to go to complex coverage rules and contracts, to forms for prior authorization, for the weekly postcards and emails that they send me telling me that they have changed your coverage? Is it any surprise that I have no idea if your insurance company covers a test? They may have last week and not this week. The overhead for medicare is 2-3% administrative costs. Now why would we privatize that when the overhead for the health insurance companies is 20-30%?
How much of your health care dollar do you want to go to corporate competition?
I don’t want ANY of my health care dollar going to corporate competition and profit. I want my health care dollar going to my HEALTH. We spend the most per person in the world, almost twice as much per person per year as the next most expensive: and we don’t guarantee care. Hello, the next most expensive and all of the other nearly 40 countries, first and second world, have universal care for all their citizens. So is our care twice as good?
No, no, no, and no.
Hello, new administration. Let’s put the health care dollar where it is paying for health…. in medicare for all and in a single payer system. We have guideline after guideline on how we should treat illnesses, here:
The guidelines are regularly updated. If we have medicare for ALL then I will KNOW whether a test is covered or not. I have memorized the entire list of medicare covered screening tests and all the details: screen for abdominal aortic aneurysm is covered in male patients age 65-75 who have smoked more than 100 cigarettes in their life and any patient who has a family history. I have the whole list in my brain.
You CAN make a difference. Write to your congresspeople, state and national. Call them. Email them. They all have websites. Tell them YOUR health care story or the story of a friend or family member.
Join Health Care Now and Physicians for a National Health Program.
I want my health care dollar to go to HEALTH CARE.
For the Daily Post Prompts: gone and interior. Interior because I am so angry at the poor spotty costly health care for my fellow people in the US. And gone: your health care dollars is GONE: let’s use the next one wisely.
BLIND WILDERNESS
in front of the garden gate - JezzieG
Discover and re-discover Mexicoβs cuisine, culture and history through the recipes, backyard stories and other interesting findings of an expatriate in Canada
Or not, depending on my mood
All those moments will be lost in time, like tears in rain!
An onion has many layers. So have I!
Exploring the great outdoors one step at a time
Some of the creative paths that escaped from my brain!
Books, reading and more ... with an Australian focus ... written on Ngunnawal Country
Engaging in some lyrical athletics whilst painting pictures with words and pounding the pavement. I run; blog; write poetry; chase after my kids & drink coffee.
spirituality / art / ethics
Coast-to-coast US bike tour
Generative AI
Climbing, Outdoors, Life!
imperfect pictures
Refugees welcome - FlΓΌchtlinge willkommen I am teaching German to refugees. Ich unterrichte geflΓΌchtete Menschen in der deutschen Sprache. I am writing this blog in English and German because my friends speak English and German. Ich schreibe auf Deutsch und Englisch, weil meine Freunde Deutsch und Englisch sprechen.
En fotoblogg
Books by author Diana Coombes
NEW FLOWERY JOURNEYS
in search of a better us
Personal Blog
Raku pottery, vases, and gifts
π πππππΎπ πΆπππ½π―ππΎππ.πΌππ ππππΎ.
Taking the camera for a walk!!!
From the Existential to the Mundane - From Poetry to Prose
1 Man and His Bloody Dog
Homepage Engaging the World, Hearing the World and speaking for the World.
Anne M Bray's art blog, and then some.
KO Rural Mad As Hell Blog 
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