Category Archives: rural doctor

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Eating sunlight

Beloved
I don’t think I can bear this
It’s a good plan
To work five more years
And retire in better financial shape
House paid off
But it hurts so

My tattered bruised and battered heart
Already patched so many times
And to see so many people each day
Hurting

Why, Beloved?
Why don’t we mature?

Maybe I’ll be a tree again
Living wood
That bends and moves with the wind
That eats the sunlight
Drinks the rain
Endures the snow and drinks it as it melts
Until spring comes
And I stir and start to bud
Deciding when it’s time
To uncurl leaves in warm sun

_______________________

For the Ragtag Daily Prompt illusion. Or should it be delusion? Or survival? Or beyond that to peace?

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Balancing act

I am working at a site in the greater Seattle area, but I am not going to say where. Why? Two reasons. One is that the patient diversity is huge: the organization is organized to take care of low income, uninsured and immigrant patients. The second is that I am still trying to decide if the balance of the organization is working. It may be working but it might not be working for me.

I am at a large clinic, with primary care, dental, behavioral health, a nutritionist, a pharmacy and three in person translators. In any one day I will probably use translators for at least six languages. English, Spanish, Dari, Hindi, Punjabi, Arabic, French, Somali and sometimes languages that I have to look up the country because I don’t know where that language is spoken. The work is fast and furious.

The overall no show rate is 20%. This makes the day very unpredictable. It can be very very fast and busy with everyone showing up and then later there are three no shows in a row. I think that the no show rate has been less than 20% but on Tuesday it was more. However, everyone showed up in the morning and there was a hospital follow up that should have had 40 minutes and only had 20 and of course then we ran later. My lunch theoretically starts at 12 but I went to lunch at 12:50 and came back 6 minutes late, at 1:06. Then people no showed while I worked to finish off everything from the morning. It did feel a bit nuts.

We are using the electronic medical record EPIC. I find EPIC epically frustrating. It is “feature rich” which means it has too many ways to do things. If I ask someone how to record a phone call to a patient, it takes eight steps. A week later I have to do it again, I ask again, and the next person shows me a DIFFERENT set of eight steps. And there have to be at least eight ways to do anything, so it is very confusing. Also, the “home” page can be personalized to the extent that people look at my version (I have not personalized it much) and say, “Mine looks different. I don’t know how to do that on yours.”

Whew. So, how to cope with the fast furious unpredictable schedule? I am “precharting”. For this Tuesday, I spent 70 minutes going through the patient charts on Saturday. Then I may know why they are coming in, if they had a heart attack two weeks ago and are following up, if it is a well child check and the last one was two years ago, if there are outstanding issues like a elevated liver tests or they have not been in for their out of control diabetes for a year. Then, of course, some of them do not show up. It is so busy that all I feel when someone no shows is some relief, like a ray of sunlight in a dark forest. Ok, the person who was horribly sick and in the hospital for a week and had surgery, they really do need to follow up. But I cannot make them, no one can.

We have live translators, outside translators who come with the patient, family sometimes translates and two phone translation systems. Our live translators cover the following. One Spanish only, one Dari, Arabic and ?maybe Russian. A third language. The third does Hindi, Punjabi and something else. I can’t tell by language who is a recent immigrant or refugee or who is a citizen of the United States for thirty years.

The clinic system has high standards for care of an often vulnerable population. However, I have not decided if it falls into a statement by my grandfather: “The higher the ideals of an organization, the worse its’ human relations.” My job in Alamosa had very high ideals, but I was fifth senior doctor out of 15 in a mere two years. A burnout job. This one has three new doctors coming in soon. My training and assistance to learn EPIC has been sparse and not up to my standards. If the new doctors are treated the same way then this is a burnout job as well. This is a place that I could work in intermittently alternating with other places in the country, but only if it is balanced for both the patients and the physicians. The jury is still out, but there are many red flags. It is a six month job and I am two months in, so we shall see.

Hugs to everyone.

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For the Ragtag Daily Prompt: nuts.

The photograph is from Larrabee State Park this weekend. My daughter came out and saw many of her friends, stayed with me, and we camped for one night at Larrabee.

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Every day

Every day
I am thankful for clean water
water to drink
water to wash
I am blessed
by clean water

Every day
I am thankful for food
Good food
to cook
to eat
to share
I am blessed
by good food

Every day
I am thankful that I can stand
that I can walk
that I can carry things
up and down stairs
I am blessed
that I can stand

Every day
I am thankful that I can hear
voices of friends
voices of my family
all the music
my cat and birds
I am blessed
that I can hear

Every day
I am thankful that I can see
all the faces
all the smiles
the trees, the ocean, the birds
the ever changing sky
I am blessed
that I can see

Every day
I am thankful that I can touch
my cat purring
a vegetable for lunch
clothes and doors
friends to hug
I am blessed
that I can touch

Every day
I think of those
who cannot touch
who cannot see
who cannot hear
who cannot walk
who do not have food
who have no clean water
and some of them
are children

Every day
I am thankful
and grieving
at the same time

And I try to do a little
it’s not enough
yet

Some day I will be gone
or we will all have done enough

And every day I am still

thankful

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For the Ragtag Daily Prompt: warning.

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Dissolution

I am sorting, Beloved.

I dream that my sister has drowned
in the ocean. A sailboat went down.
There were others on board.
Two friends ready me to dive and find her.
I don’t want to scuba dive, I am not trained.
I don’t know how to use the equipment.
I am afraid I will drown too.
I see her daughter, who is four.
Her daughter knows from my face that her mother is lost.
My friends say, “You will be able to find her.
You can find your sister.”
“But she is dead,” I say.
“I don’t want to find her.”
I know that they are right, I could find her.
But I might be separated and lost, in the depths.
I don’t want to die too.

I wake up.
The dream sticks.
My friends wanting me to wear a borrowed wetsuit
and scuba gear and go down untrained.
My sister floating in the depths, dead eyes open.
But she has been dead for years, I think.
And this is the sea of dreams
my unconscious
the greater unconscious
everything.
So why isn’t my sister’s body dissolving?
Changing to a skeleton.
A skeleton coming apart over the years.

I don’t need a wetsuit
or scuba gear
to dive in the sea of dreams
I can breathe in the unconscious
I have been to the bottom of the sea
many times before.

My niece is four in the dream.
She was thirteen when her mother died.
I think she was lost to me long before that.
The dream knows.
Her mother was lost to me
when my niece was four.
Drowned.

When the dream returns
I will say yes to the dive
I love the sea and the ocean and going deep
I don’t need a wetsuit
I don’t need scuba gear
I don’t need to find my sister’s body
She is gone
Dissolved
I let my past go.

I have not dreamed of the ocean

since.

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I really don’t know where my sister is, because of the family schism after she died. Are her ashes somewhere?

This poem wanted to be born. For the Ragtag Daily Prompt: Who knew?

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Hungry

Each time I’ve gotten pneumonia, I drop ten pounds in a week. The weight stays off, each time for longer. Then I gain it back and go past my “normal” weight. It takes work to get that extra weight off.

I have been trying to lose that extra weight since the start of the year. At first I just tried to increase my vegetable intake. The green, yellow and orange vegetables have the lowest calories and carbohydrates. The grains and rice and potatoes and bread are all more dense and have more calories and carbohydrates. I tried to go easier on them.

I did not make much progress. The climbing gym has been building muscle and clothes fitting better, but the scale did not move much.

I started having conversations with my stomach. I would eat. My stomach would demand more. “HUNGRY! WANT MORE!” This is not real hunger, as the people in occupied territories are having. This is my stomach or hindbrain fussing. It was easiest to control at lunch. I would fill half my container with spinach or mixed greens and then add more vegetables or tuna salad or egg salad or humus and vegetables. I would take a piece of fruit. Once that was done, we were done. “HUNGRY!” my stomach would complain. “That’s ok,” I would tell myself, “It’s ok to be a little bit hungry. We’ve had enough food. Stop fussing.”

My stomach fussed a lot at first. Now it is more of a query: “Hungry?” “No,” I reply, “we’ve had enough.” It seems to quiet down much more quickly. I think I am losing weight but I have no scale here and haven’t remembered to weigh myself in the last 3 weeks at work. Never mind. I have more muscle, at any rate, which is denser than flab. Muscle burns 9 kcal/gram and fat burns 4 kcal/gram. I climbed yesterday at the gym and might again this afternoon. It did take weeks or a couple months for my stomach to quiet down. Changing habits is not easy.

The tuna salad and spinach and green chili dish was my breakfast this am. I don’t think my stomach complained at all after it. It was distracted by packing and clearing out the refrigerator and cleaning. Sol Duc knows I am packing but is pretty sure she is going with me. I have been putting her toys in the carrier and she’s gone in and out to suss out the situation.

I hope all the people who are suffering from hunger get fed, today and tomorrow and the next day.

For the Ragtag Daily Prompt: hungry.

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Done and undone

I am done with my third Grand Junction travel doctor assignment and packing to go home. I don’t think much of my temp company at the moment. I had to nag them for two weeks regarding the travel plans. I had to call both airlines (one hour 18 minutes and one hour 38 minutes) to be sure that taking Sol Duc on board the plane is arranged (it wasn’t). I called the hotel for the day between planes and they do not take pets. I called the company that takes me from the airport the last two hours home and they DID know about the cat. One out of four. They finally switched the hotel on Friday, the last day of work.

Then at 5:18 pm I am sent an email saying I have to vacate on the 19th. The first plane is on the 21st. It was sent by the rep who is covering me and knew the travel arrangements are for the 21st. I am glad that I pay way more attention to detail as a physician than they do to my travel and housing. They frankly suck. And I am not vacating until Monday. They may charge me at which point I will say they need to pay me for spending more than 5 hours fixing their travel screw ups.

I did say to the rep on Friday, “Well, if it’s not arranged today, I will just call the emergency travel line at 5:01 pm. They will help me.” The emergency travel folks cost them more money. That apparently caused them to do the last arrangements. I am doing the travel in two days because otherwise my cat would be in the carrier for 12 or more hours. That is not reasonable.

I am done except for travel home. Today I finish packing and cleaning.

The photograph is Sol Duc in front of our rental house yesterday. I think she will miss the heat here. She seems to quite enjoy 90+ degrees.

________________________

For the Ragtag Daily Prompt: done.

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Experience

Friday I left for the Fourth of July, but not for fireworks. I went to help pack for a move. My family moved every 1-5 years through my childhood, and then I moved too. College, work, work, medical school, residency, first doctor job. Second job and I stuck: I have not moved for 25 years. Travel yes, move no. But like Martha, I am thinking about all those books! I am working on cutting them down to size and many fewer favorites.

Anyhow, I have quite a bit of experience packing and moving. When my family moved from upstate New York to Alexandria, Virginia, the movers stacked the plates with newsprint between. Every single plate in the pile broke. My mother was furious. She said the packers should have nested them on their sides, so they don’t break the one below. We shall see if my experience is useful or not.

I bubble wrapped this lamp and then packed it in a big box with more bubble wrap and a lot of t-shirts. Yes, I should take the shade of but it would have required a special tool that we didn’t have. Or a trip to a lamp store. There was not enough time. The moving truck comes Wednesday or Thursday. We were nearly done when I left to drive back to Grand Junction. Newsprint, bubble wrap, a pack for glasses and quite a few boxes. I hope it all makes it!

For the Ragtag Daily Prompt: pack.

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Choose the best

If you are going to have a knee replacement , you would try to choose the best surgeon, wouldn’t you? Yes. I am thinking of this because there is an illness where people often refuse the best. Not once but over and over.

I receive a card in clinic, a few days after a rather difficult day. Initially I don’t want to open it because it could be a yelling at me or threatening card. Hand delivered to our front desk. I open it and the card says what great care I give.

Wonderful, right? Except that there is a letter too, asking for a refill.

Most refills come through the pharmacy. Why a card and a letter? Have you guessed yet?

I call my patient. The patient was referred to the best addiction specialist in the area. The patient is not going to go to the specialist. The patient is not going to go to the group therapy, inpatient or outpatient. They can do this alone.

I let them know that I am not the local expert. I fail to change their mind. Yes, I will do a refill, but if they won’t see the expert, they have to come see me. Regularly.

This is typical for addiction. Denial and charm. A sweet card but trying to obscure that the patient is not going with the best treatment. I think of it as the drug or alcohol stil in control and whispering to the person: you are not really addicted, you don’t need anyone else, you can do it by yourself, we got this.

Chance of relapse? Well. I pretty much expect it. I would see this person monthly at least.

In what other illness do we refuse the expert, refuse help, refuse the best and say, I can do it alone?

For the Ragtag Daily Prompt: best: https://ragtagcommunity.wordpress.com/2025/06/29/rdp-sunday-best/.

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Hormones and rabbit holes

Medicine is confusing right now. Ok, it is always confusing because we try to base it on science and science is always changing. There are always special areas that are currently a mess. Hormones!

I speak to a patient recently who is female, premenopausal, and is getting hormone replacement therapy for hot flushes and not sleeping well from an outside source. The person wants me to order hormone tests. I do order hormone tests but not the ones she has in mind. I test a TSH, thyroid stimulating hormone, to see if she is low or high in thyroid.

She is thinking of me testing estrogen and progesterone and other related hormone levels. The party line from gynecology MDs and DOs is that these are not useful tests because women’s hormone levels are so varible. However, there are lots of naturopaths out there and functional medicine MDs and DOs who will test levels. Why is the patient asking ME to test them? Most of those naturopaths and functional medicine providers do not take insurance and charge cash. Also, insurance may not pay for them anyhow because the party line is that they aren’t useful. Why would the cash providers check levels? One reason is CASH. Another is to prescribe “bioequivalent hormone replacement”. Sounds natural, right? Well, the natural thing was for the hormones to stop at menopause and all of the hormones are either made in a laboratory from plant pre-estrogens or from pregnant mare urine, so bioequivalent seems to imply natural but it really isn’t. Pills do not grow on trees, they are made by humans in laboratories.

However, I question party lines, and off I go down the hormone rabbit hole. The current guidelines are that female hormone replacement, after menopause, should be lowest dose possible and only for a maximum of three years because of the increased risk of breast cancer. This doesn’t address my question: does premenopausal hormone replacement count as part of those three years? I may need to ask gynecology. I don’t think it counts. A woman is postmenopausal when she has had no periods for a year. Or had her ovaries removed. Or if she’s had a hysterectomy and still has her ovaries, a yearly follicle stimulating hormone and lutienizing hormone test. Both tests rise when the ovaries stop making hormones and eggs.

Also, there is another caveat. We know that when men are on opioids, the opioids can suppress their hormones and lower testosterone. Here is a paper: https://pubmed.ncbi.nlm.nih.gov/31511863/. Half the men studied in multiple studies had low testosterone when on chronic opioid therapy. 18429 subjects (patients) in 52 studies. That is a lot. Women studied? NONE. What? Yeah, none. Why? Here is part of the answer: about a decade ago I worked with the UW Telepain group and asked the head of the UW Pain clinic a question. “If opioids lower hormones in men, do they in women too?”

His reply, “I don’t know.”

“Have you ever tested a woman?”

“No.”

“Isn’t that sort of sexist?”

“Yes.”

So here I am, rechecking a decade later, and we still don’t know if giving women chronic opioids messes up their hormone levels. It would be more complicated and difficult to check women. We might have to do individual hormone baselines or something in premenopausal ones, say, 2 weeks after menses. Remember that for most of the history of medicine, clinical drug trials were only done in men, because, well, sexism. They said women could get pregnant. Yes, but then we gave the drugs to women who could get pregnant. Also, postmenopausal women can’t get pregnant. The whole thing seems stupid to me.

There is an interesting new finding here: https://neurosciencenews.com/estrogen-t-cells-pain-28548/ . Apparently in women, estrogen and progesterone work on receptors at the base of the spine to reduce pain signals using T cells, part of the immune system. The article says this doesn’t happen in men, but they were studying mice. The male mice didn’t seem to have worse pain after estrogen and progesterone were blocked. The female mice were in more pain. But wait, estrogen and progesterone are produced in men as a by product of making testosterone. Less than women, until menopause. Then the 70 year old man has more estrogen and progesterone than his postmenopausal wife. The article says that they don’t know why the receptors are in women and female mice (um, my intuitive guess would be childbirth and micebirth, right? Men don’t do that and women giving birth to a child after the first one sometimes say, “WHY did I want to do THIS again?” I think those receptors are so that women and mice can get through more than one pregnancy.) Now I need to read the article again because maybe men and male mice don’t have the receptors, even though they do have some estrogen and progesterone. Maybe they just don’t have enough estrogen and progesterone.

Maybe we can’t figure out women’s hormone because men aren’t smart enough, heh, heh. Yes, that is sexist right back at all those historical figures who didn’t study women.

At any rate, that still doesn’t answer my two questions: does premenopausal hormone replacement count towards the three year total beyond which hormone replacement increases the risk of breast cancer? And does chronic opioid treatment lower women’s hormone levels?

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For the Ragtag Daily Prompt: hormone.

I took the photograph of a Port Townsend rabbit in 2011.

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Concord

my heart is broken
love doesn’t conquer all
unselfish love
unreturned
unrequited
opens me to wound after wound
some turn from love no matter what
cling to the lies they tell themselves
cling to the poison they embrace
turn from love into the uncaring bottle
turn from love into the insensate smoke
turn from love even to the grave

I wish my heart would let them go
and heal

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My friend Liz took the photograph, half way through the Rainshadow Chorale concert last Sunday.