Category Archives: rural doctor

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Patients or profit?

We can choose single payer, medicare for all, with overhead of 3-4 percent. That means 96-97 cents out of every dollar goes to HEALTH CARE, not PROFIT.

Or we can choose PROFIT:  the current law says that the private insurance companies have to spend 80 cents of every dollar on health care. 20 cents to PROFIT.

The insurance companies’ goal is to earn money, PROFIT, not give health care.  They are posting BILLIONS in profit.

The person on the phone who says your medicine or care is not covered? I think the insurance companies say that is health care. They are paying the person to refuse your care. They send us weekly updates on what has changed in the 1300 different insurance companies and I don’t know how many insurance plans because they all have more than one. You ask me, your doctor, if something is covered and I say, “I have no idea. It was covered last month. It should be covered. I don’t know.” The insurance companies pay people to write an individual website for every insurance company: 1300 websites. Can YOU keep track of 1300 log ons and 1300 passwords? And I think the insurance companies say that the money paid to set up the website is health care. I don’t think it’s health care, do you?

I want my health care dollar to go to HEALTH CARE not PROFIT.

Stop the bill. Stop the insanity. Stop putting INSURANCE COMPANY PROFITS in front of HEALTH CARE. We the people of the United States can decide and can tell Congress what we want.

Medicare for all, one set of rules, 3-4% overhead, we are one nation, under God, indivisible.

And we do not put profit first.

Physicians for a National Health Program: http://www.pnhp.org/

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sing

On Sunday we had a two hour choral practice, for the concert this Thursday. I go for a walk in the sun up in the hill behind North Beach afterwards. I am still singing the Numberless Stars piece. I am in a small quartet, first alto angel. We will sing from the balcony with the rest of the chorus in the main part of the church.

I walk by a tree and a squirrel chatters at me, scolding. I laugh and sing back to the squirrel.

The squirrel stops chattering and comes down the tree. Around to the front about three feet up and just stays, listening.

on trunk

 

She goes out the branch and sits, looking at me. She does some grooming and nearly goes to sleep.

By now I am singing “Squirrels, squirrels,” instead of the correct words, which are “Stars, stars.” A man walks by with two small dogs on a leash. My squirrel does not budge and the dogs don’t notice. The man laughs at me singing to a squirrel.

I sing to the squirrel for a while and then walk on. How magical, to have a creature listen and even relax!

Here she is, nearly asleep…..

sleep

 

 

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There is no blame

This article came up yesterday on Facebook:

http://articles.latimes.com/2013/apr/07/opinion/la-oe-0407-silk-ring-theory-20130407

How never to say the wrong thing….

Well, now, wait. What the hell is your goal? To always comfort people? To always say the right thing? Peaceful and sweet and niceness all the time?

Why?

And isn’t it dishonest?

Isn’t a true friend that loves you the friend who says, hey, this guy you are dating sounds just like the last one, didn’t you say you weren’t going to do that again?

Even if it makes you mad. And you forgive them because damn it, they are RIGHT. You might not forgive them right away. It might take a while. You might shun them and then have to do some crawling and apologizing.

Our society is terribly afraid of emotion. Don’t say the wrong thing. Do not make someone angry, afraid, never ever hurt anyone.

Except…. I am a physician. And I’ve had my mother and then my little sister die of cancer.

With my mother, we did what she wanted. She was home for 6 weeks in hospice. My sister and I cried for two minutes after I told her the surgeon said feeding her iv would kill her faster. We took her home on iv fluid and morphine to starve. She was tough tough tough. We had over thirty visitors from as far away as London.

My partner was her doctor. She did a home visit and she cried. Afterwards my mother said, “I didn’t appreciate that.” So we did not cry.

My sister did one day when I was at work. She started crying after my mother was asleep in the hospital bed. She called me. “I started crying. And everyone left. Everyone left the room. Not one person stayed with me.”

Ouch. Now I can see that once my sister started, everyone was afraid that they would start too. So they all left.

I stopped talking. In the fifth week, family called and I was handed the phone. “How is she? Are you ok?” I just held the phone. I knew I was supposed to say reassuring things, I am ok, she is ok, but I wasn’t and she wasn’t. She was dying and I was broken, weeping inside. So I just held the phone, silent.

My mother died. We were all exhausted. And for the next two years I thought about it…. and one thing that I thought was, I wish she had let me cry. I did what she wanted. We all did. But in the end, I never got to cry with my mother and say how much I was going to miss her.

And maybe she would not have appreciated it. But I am her daughter! Don’t my feelings and wishes matter? There are two of us in this relationship!

Then my sister got breast cancer. At age 41. Stage IIIC. And this time I thought, I will be different.

I refused to do what she wanted. I told her I loved her, I told her when I was mad at her, I told her when she was hurting my feelings and when she was being wonderful. I held BOTH of us close. I held her close but I refused to let her go into the cancer bubble where no one was telling her the truth.

I was dating a man who complained. He told a couple’s counselor: “I want her to do what her sister wants or cut her off.” I explained about my mom. I explained about the cancer bubble, where people stop being honest and only do what they think you want. The counselor defended me.

And I think I did the right thing. For me. AND for my sister. Because our last day together, she thanked me and she even apologized for something… and I got to say “I love you anyhow.” I meant it to my bone marrow. People yelled at me for being grumpy, bitchy, not doing what she said…. but I was my real self with her. And she knew it. And she also knew I love her and stayed real with her.

In the hospital when someone is very sick, families fight. They argue. They get angry. The emotions are running high. The doctors, the nurses, the janitors, the desk people, we are used to it. People yell, they cry, they behave badly. But their hearts are breaking, why would we expect them or order them to behave well? Honestly, sometimes they work off some of the anger part of grief by fighting with each other.

In clinic sometimes I am handling a room: a person with cancer with a spouse and one or more children. Adult children. People handle death in different ways. Siblings fight before and after a death, “You aren’t doing right.” We are all different. The way I grieve is different from the way you grieve. There is no wrong, there is no blame.

My sister wanted to handle her cancer with grace. Grace, it’s complicated. For me, the greatest grace is honesty.

I want to die singing, crying, going to see the people I love that are gone, and honestly. The I Ching sometimes says there is no blame. Think if we could all accept each other’s honest emotions. The most beautiful harmony is sometimes the resolution of dissonance. Goodbye, goodbye, I will miss you so….and there is no blame.

 

For the Daily Prompt: harmonize. I took the photograph of my sister four days before she died.

 

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Templates and the death of medicine

One of the many problems that are killing medicine in the US and especially primary care is templates.

Templates are a nightmare.

Why?

In a template, for back pain, there is a list of questions and in some there is also a list of answers. The “provider” asks the questions on the list and then checks off the answers. This is absolutely terrible brainless stupid failure of medicine. Because the most important answer that the patient gives is the one that does not fit the routine pattern of back pain or ear pain.

For example, I saw a woman for a new patient visit for back pain. Years ago. Half way through the questions about back pain I say, “How long have you been hoarse?”

She stops. She has to think about it. “Three months.”

“Continuously or does it come and go?”

Again, thought. “Continuously.”

On with the back pain. But she gets TWO referrals, one to an otolaryngologist. I ask other voice and throat questions.

When she returns she thanks me. Continuous hoarseness is worrisome for vocal cord cancer. You have to rule it out. She did not have vocal cord cancer. She did have vocal cord polyps and was going to have laser surgery.

But as a physician or “provider” you have to PAY ATTENTION. And ignoring the thing that doesn’t “fit” or isn’t relevant or isn’t on the god damned template — just don’t do it.

Another new patient. Back pain. Routine, routine, routine, one in four people get it in their lives. All the questions indicating that it’s musculoskeletal, not a disc, 99% are not discs, until:

“Sometimes my leg goes numb from the knee down.”

I stop. “How often? The whole leg?”

“Whole leg, yes.” She doesn’t know how often.

“If that happens I want to see you right away. Call.”

…because that is not a disc and it’s not musculoskeletal. And people say that but usually it can’t be confirmed on exam.

She calls. “Both legs are numb from the knee down.”

“Get in here.”

On exam she is not only numb but the muscles of her feet and ankles are weak and the reflexes don’t work right. I call neurology, anxious. “MRI from her head to her tailbone.”

She has multiple sclerosis lesions, more than one, in her brain. And a normal brain MRI from a few years before when she also had weird symptoms….

So it is NOT the template, the routine questions, that diagnose odd things in medicine. It’s the off hand comment, the puzzle piece that doesn’t fit, the symptom or sign that I notice and that gets my attention.

I hate the templates when we first get an electronic medical system. It sucks. It generates unreadable generic sentences: “The patient has ear pain. The quality of the ear pain is sharp. The ear pain has gone on for 6 weeks. The level of the ear pain is high.” Etc. Ok, that patient sounds like a robot. I quickly figure out how to type into the stupid boxes and avoid the templates as much as possible. I also start offering additions to the templates. “Ok, add this to quality of ear pain: It feels like being kicked over and over with the metal pointed tip of a cowboy boot.” Also to tachycardia: “It feels like a salmon is swimming upstream in my chest.”

See patients for one thing only. That would have really helped the hoarse woman, right?  Do the template. Do 10, 15, or 20 minute visits. The best doctors are rebelling and quitting, especially in primary care, because this is killing medicine. Why see people for one thing only? MONEY. MONEY MONEY MONEY. No. I like to work in medicine and I like to dig down, pay attention, listen and watch for the little details that stick out, the puzzle pieces that don’t fit….

….because that is what real medicine is. Not template robot medicine.