Category Archives: love

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Slow medicine

I am practicing slow medicine, just like the slow food movement.

It took a year to set up my clinic, because I wanted time with people more than anything. And how could I do that?

Low overhead, of course. The lower the expenses, the more time I would have with patients.

I did math and based it on medicare. I estimated what medicare would pay. I dropped obstetrics, can’t afford the malpractice and anyhow, the hospital was hostile by then. That cuts malpractice by two thirds. And I chose not to have a nurse, because people are the most expensive thing. Just me and a receptionist. And a biller once a week and a computer expert who rescues us when we kill another printer or need new and bigger computer brains for ICD 10.

My estimates were on target except that it took three times as long to build up patient numbers as I thought. Ah. Oops. I was advised to borrow twice what I thought I needed and that was good advice, because I had not counted on my sister dying or my father dying or me getting sick for a while…. but so far the clinic remains open.

Slow medicine. I schedule an hour with a new medicare patient or anyone new and complicated. People who say they aren’t complicated are lying, but we schedule 45 minutes for them. And for the really complicated, we have 45 minutes for follow ups. Most visits are 25 minutes: the only visit that is less is to take out stitches.

What does slow medicine allow? In the end it allows people to speak about things that they don’t know they need to talk about. A friend dying. Fears about a grandchild. Family fighting. The dying polar bears. The environment. This difficult election. And sometimes I think that freedom to speak about anything is the most theraputic part of the visit.

I had one woman last year who established care. Complicated. I think she was in her 70s. And the medical system had made mistakes and hurt her. Delayed diagnosis, delayed care. But she was laughing by the end of the visit. She stood in the hall and said, “This is the first time I can remember laughing in a doctor’s office. This is the first time in years that I can remember leaving with hope. And you haven’t DONE anything!”

….anything, except give time and listen.

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Choosing love

My sister and another writer posted essays under the title Choosing Love here: http://everything2.com/title/Choosing+Love. My sister’s was written in 2002. I posted mine there last November.

Choosing Love

I choose love
I have no enemies
I hold you close in my heart
and hug you close if I can
and if you hurt me over and over
I can still love you
I choose love
I have no enemies
I hold you close in my heart
from far far extremely far away
I choose love
I have no enemies
I hold you close in my heart
I hug you from a safe distance
I choose love
I have no enemies
I hold you close in my heart
even if I will not allow contact again
I choose love

The photograph was on the beach. The gull and the crow were interacting. After I watched for a while it was clear that the gull was following the crow and trying to take things from the crow. They were not friends.

 

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Diagnosis is only half the job

In clinic I have two jobs.

The first job is to diagnose. Chief complaint, history of present illness, past medical history, allergies, review of systems, medications (and vitamins and supplements and herbs and any pills or concentrated substances), social history including addictive substance use, family history, physical exam. What is my diagnosis? A clinical portrait of the patient.

The second job is to communicate and negotiate. I have to get a snapshot of the person’s medical belief system, their past experience with MDs, their trust or lack of trust, whether they are willing to take a prescription medicine. I have to try to understand their world view at this visit, at this moment in time. And it’s not static and may change before I see them again. If I can understand the person well enough to communicate with respect, with concern, with understanding, then we may be able to negotiate a treatment.

In clinic the other day I had a new patient who said, “I am not going to be pushed to take prescription medicine.” I responded, “That’s fine. I am not going to be pushed to do medical testing that I think is inappropriate, either.” She actually laughed and said, “Ok. That’s fair.” This is a patient who is coming from alternative treatment but wants medicare to cover her tests. After the visit she called and said that her provider wants a certain test before they feel comfortable proceeding with a therapy. I responded that I need a note and an explanation of the planned therapy before I will order the test. (Honestly, it’s an increasing trend that I get calls from patients with messages like “My orthopedist wants you to get my back MRI prior authorized.” and “My physical therapist wants my hand xrayed.” Our new office policy is: the provider has to communicate themselves, not via the patient. Also, it ain’t always so….)

I had patient once in the emergency room who said, “I have an antennae in my tooth. Get it out.” Her roommate nodded, looking terrified. This was after a fairly confusing complaint of tooth pain. I needed to think about an approach. I said, “I need to check on another patient. I will return.” I left the room in the emergency room and considered approaches. I went back in and said, “I am not a dentist. I can’t take out the tooth. BUT I can call a doctor to help with the sounds that you are hearing until we can deal with the tooth. The doctor is a psychiatrist.”

“Ok. Call them.” said the patient. The roommate practically collapsed with relief. Psychiatry said, yes, looks like psychosis and we have a safety contract and she will come in Monday. People HAVE actually had metal in their mouth that picked up radio sounds, but psychosis is much more common. Also, if you can say the station call sign that is a lot different than voices that are telling you to harm yourself.

I thought about my approach carefully. I did not want to argue about the tooth. I wanted her to agree to talk to psychiatry. So I told the truth: I can’t fix the tooth. It’s Saturday night. Here is what I can do. I never said, hey, I don’t think it’s the tooth, I think it may be a psychotic break. She may have known that it was not the tooth but been too terrified or too disorganized to tell me. And there was a small chance that in fact, it WAS the tooth.

It is not worth trying to “fix” or change someone’s world view. If they trust their naturopath more than me, that is ok. But it’s a negotiation: I am a MD and I will do treatments that I think are appropriate and safe and I may or may not agree with the naturopath or chiropractor or physical therapist or accupuncturist or shaman. But the goal in the end is NOT for me to be correct: it is to help the patient. Half the therapy is respect and trust and hope. And kindness.

The biggest problem with ten minute visits and the hamster wheel of present day medicine in the US is that the second job is often not possible. Complex diagnoses are missed or patients leave feeling unheard, not respected and frustrated. Time to make the connection and to understand is very important and is half the job. Physicians and patients are frustrated and it is only getting worse.

 

The photograph is my daughter and her wonderful violin/viola teacher, right before my daughter played for a music competition.

 

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Rare: morning coffee

This is for the Daily Post Photo Challenge: Rare.

I had my morning coffee on Sunday in the tree house, very early. Coffee is not so rare but having it in a tree house is not common for me!

We have three of the four roof panels in place, but the fourth will have tricky cutouts to accommodate the tree. I love the clear roof panels that let in the light. I can watch the leaves and the tree move through it. We have a window that fits in the open space, but took it down to paint the outside…..so far I have not had time….

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Mergansers

These are some of the creatures that I saw last summer at Lake Matinenda. A whole family of mergansers swam around the point in the early morning. I was drinking tea and writing in the very early morning. Suddenly they startled at something in the water and all rushed up on the rock ten feet from me. I froze and when they didn’t notice me, I slowly picked up my camera.

What were they scared of? There are pike and lake trout and otters…

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Rain on water

My sister wrote Rain on water and posted it on everything2.com in 2009. Here: http://everything2.com/title/Rain+on+water

She was writing about going to Lake Matinenda. Our family has had land with cabins since the 1930s and now the fifth generation has gone there.

My sister died in 2012. I wrote my own version while I was there last summer.

____________________________________

What are you doing?

nothing

outwardly nothing

Inwardly, I am on a journey. I am back at the lake. It’s been three years. I am at the lake when the family is not there. I take old friends who have never been there. One knew my sister as I did and has known me for thirty years.

He and his wife and his six year old love the lake. And the six year old wants freedom as we all want but there are rules and you must wear your lifejacket on the front rocks until you can swim and can swim a certain distance and we never get in the canoe when it is on the rocks, it must be in the water or the canoe will be hurt and my uncle’s shade is over my shoulder and I can hear him yelling about the canoes as his parents yelled at him. The birchbark canoe that he and my mother destroyed still awaits repairs. And I demonstrate how to tip a canoe over when we go swimming and how fast it goes. “You may try it, but first you must practice jumping in the water. Do you want to?” No, he shakes his head, no, the small canoe went over so fast.

They leave and I am alone. I am not alone. The dead are there, their ashes, their words in the log, their voices in my head, their heights marked on the wall of the Little Cabin, my sister’s clothes, a marker for my uncle, my grandmother’s bed has been taken apart and is now a bench and I grieve about change and loss but it goes on. My sister is a sea otter but there are no sea otters at the lake and she is at the lake with me because she said, “How will I find you?” and I told her how and she was satisfied. No sea otters, but there are river otters, they come, a family, three, playing and fishing. I sing to them, Pie Jesu and they watch me curiously and go back to fishing and I think of my father my mother my sister and that I think they would be happy to be river otters in the lake together and fishing. I am with them almost and crying. My grandmother is a white pine and in the mink, my grandfather is a dragonfly, my uncle is the snapping turtle, I wonder what my friend’s son is, dead at 22, and the next animal I see is a merganser, the hooded merganser with two babies and she is leading me away from them while I am in the canoe, they are hidden I know about where and she circles back to say that now they can come out and are safe and I think yes, that would be right, a child who grew to a young man and was lost, he might choose to be a mom next caring for these young and careful and nurturing them, protecting them, hiding them, leading danger away.

Loons call and I answer and my voice lessons have helped my loon calls, I can hit the high notes now. A long conversation with a loon with me in the blue canoe and the loon wondering, do I have a loon trapped in my boat or am I in fact a loon, yes, I think I am, I will be a loon not a human any more

I can’t swim for long, not yet strong enough, the taste of the water is ingrained, layers of memory back to five months old and beyond, in the womb, has the lake marked my dna in three generations, I don’t know but I am in the water I am of the water I am water tears and water

written 8/29/15