Category Archives: rural doctor

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Fraud in medicine: mail order pharmacies

My clinic refuses to fax to mail order pharmacies. Instead, I give the prescription to the patient and tell them to mail it.

I started this policy over a year ago, when five different patients called in the same week, about two mail order pharmacies.

Patient: “I called my mail order. They say that they don’t have the prescription and the doctor just needs to cal.”

I check. Each of the prescriptions had been faxed. I called the two companies a total of five times that week. Each time they would ask for my identifying information, the patient’s identifying information, transfer me and then say, “Oh, yes, we have the prescription.”

Ah. This is a nice example of triangulation. The patient calls for their refill. The mail order company faxes me a request. I check the chart, see if the person is due for labs or a visit, and fax the prescription. Then the company sits on it. The patient calls them and the company says they don’t have it. They delay. Finally the patient calls me to call the company and then the company admits, oh, yes, actually we do have it.

So we refuse to fax to these companies.

Last week I saw a patient who had mailed her prescriptions. She did not get her medicine.

“I called the company five times. They told me they didn’t have it. They said to call you to send a “hard copy”. I said, “I mailed it to you myself on this date.” Then they said, “Oh, yes, we have it.” However she was out of her medicine for three weeks.

I said, “They saved the cost of three weeks of medicine. That is fraud.” I explained the scam.

Comprehension dawned on her face. “They do it on purpose?”

I shrug. “Five in one week seems like a business operation to me. I recommend that you write to the state insurance commissioner.

She said, “Next time I will mail it certified. And yes, I will call the insurance commissioner if they do it again.

The patient main insurance sends information that getting the prescriptions mail order will be cheaper, and so people want to use the mail order: but the mail order pharmacies in our area are saving costs by ripping people off and delaying prescribed medicine. I do hope they end up in jail: if we can’t jail the corporation, let’s at least jail the CEO and the top 4 officers.

I took the picture yesterday at sunrise.

 

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Dream state

I am in the soft dream state
longing for my love and mate
my heart won’t stop or hesitate

I cross the border into dreams
nothing quite is what it seems
I stop and play in bubbling streams

I wander in the tall green grass
years since the mower’s pass
unsullied by the smell of gas

I lean against a tree
I feel quiet happy free
I feel accepted just as me

my childhood was a frightened place
the woods were the safest space
if I spoke my heart would race

my work is with adults in pain
scars deep as canyons bleeding strain
my tears fall as gentle rain

my youngest child has reached eighteen
she’s bright and smart and kind not mean
I wonder what her eyes have seen

my adult work is nearly done
it’s time for me to have some fun
beneath the tree in moon or sun

I wander as a child
heart gentle meek and mild
connected to the world so wild

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Fallen

I took this photograph outside the Weyerhouser King County Aquatic Center, where my daughter was one of the many WA state high school swimmers. It rained driving all the way there, rained the entire time we were there and then rained on my entire drive back…

This is for Photrablogger’s Mundane Monday Challenge #33. Water again, but now the beauty of water and leaves and asphalt….

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Safe harbor

For Ronovanwrites haiku challenge #70, prompt words cover and color.

cover, shelter all
colors, would you harbor me
should be a cover

Sweet Honey in the Rock: Would you harbor me? https://www.youtube.com/watch?v=i0XBXJjoXJ4

I thought about cover meaning shelter and meaning the song, and the refugees needing shelter, harbor and cover. We are frightened and seek cover, shelter, harbor. Who do we have to harbor us but each other?

The photo is a synchronized swimmer in 2012.

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Rural medicine crisis: Job offers

One of the signs that we are entering a worse crisis for rural medicine is job offers.

I am starting to keep the email job offers: so far the record is from Texas, a random out of the blue job offer for $500,000 yearly.

One half million dollars for a Family Practice job. I won’t take it. I like my clinic and anyhow, the pace they would set me to work is burning out physicians. They are quitting, though some die instead. A recent article said that this year a physician poll reports the number at burnout this year has risen from 40% to 50%.The job offers roll in. I get phone calls, emails, mailing and now my cat is getting rural family medicine job offers. Really. Desperate times.

Years ago I read that only 30% of family practice doctors are willing to take a rural job and that only 30% of those are willing to do obstetrics in a rural area. I did obstetrics as part of my practice from 1996 to 2009. I stopped when I opened my own practice, because the malpractice price tag is three times as much and my rural hospital was grumpy at me. Starting in my third year of medical school, I did deliveries for 19 years. During my nine years here, the cesarean sections were done by the general surgeons and we did not have an OB-gyn. I called Swedish Hospital Perinatology when I needed help. I got to know them well enough that if I had someone in preterm labor I would call and find out who was on call BEFORE I chose a medicine, because I knew which perinatologist liked terbutaline and which one would rather I would skip it and use procardia. They were fighting out the research: I didn’t know who was right, but it is a huge benefit to have your consultant be happy with your choice if you have to lifeflight the patient by helicopter at 3 am. With a 25 bed rural hospital, we try not to deliver a baby under 35 weeks, and it’s better to fly the baby in mother if you can’t stop the labor.

Back to the numbers: so 33 out of 100 family practice doctors will take a rural job and only 11 of those are willing to do obstetrics. Our first day of medical school, the faculty said, “Shake hands with the person on your right. Shake hands with the person on your left. At least one of the three of you will be sued for malpractice in your career.” Oh, goody, let’s start training with paranoia. Or is it just being realistic and prepared?

I worked for five years between college and medical school and took the GREs first. I thought I was going to get a PhD. However, I did not want to write a thesis and did not want to be one of three world experts in anything. I had a friend who was one of three world experts in honeybee behavior. I asked what happened when they got together. “We argue.” he said. I also did not want to publish or perish, tenure was becoming more of a problem and anyhow, I did not want to be tied to a university. I got a job working as a lab tech in the National Cancer Institute at NIH in Bethesda. Two years there gave me my answer: primary care is the ultimate generalist. I could work anywhere in the world, in a city, in a small town, and there is endless lifelong learning. I took the MCATs and got into medical school, determined to do primary care.

Back to the job offers: 450K for Iowa. 310K, 350K, signing bonus, paid move, 6 weeks “off” (As far as I can tell it’s always unpaid leave. No sick leave, no paid holidays, no paid leave at all. Do factor that in.)Production bonus. No call or phone calls only. Near a city! In a city! Cheap houses! Excellent schools for your children and 6 stellar golf courses! FP job in Texas, 315K, 4 day work week, signing bonus, loan forgiveness!

The most that I’ve made in a year, I think, is less than half the listed average income for family doctors, though that has risen by nearly 1/3 in the last ten years. And that was enough and I didn’t see enough of my two children and the next year I worked less. I have never made the “MGMA average” for what a family doctor makes and it was more than ten years ago. I am below average in income but I think I am above average in personal happiness and way below average in burn out! I made way less last year, because I was out sick for 6 months. Ok, I lost money. However, my clinic still nearly covered expenses and stayed open, with no provider from early June to November 15, thanks to my receptionist, my patients, the PA who stepped in in November and the other independent practitioners in town. The hospital system refused to help except that they took over my 18 patients on controlled substances… after I threatened to complain to the state that they were refusing care. How nice.

I have an old house and old cars. I have a son finishing college and a daughter about to start. More money to retirement seems like a good idea. I now have 25 years as a member of the American Academy of Family Practice and I am an “old” doctor, because I didn’t retire at 50. I told a younger partner at the hospital that I was deliberately being “below average” because I was going for a career with longevity and wanted to avoid burning out. He left town last year….

From the American Academy of Family Practice paper http://www.aafp.org/about/policies/all/rural-practice-paper.html : family practice providers are 15% of physicians in the US, but do 23% of the visits each year. And in rural areas about 42%. “In the U.S. as a whole there is 1 Primary Care physician per 1300 persons while in rural areas the ratio is 1 Primary Care physician per 1910 persons and 1 Family Physician per 2940 persons. In the most rural counties, those with a community of at least 2500 people but no town over 20,000, close to 30,000 additional Family Physicians are needed to achieve the recommended 1:1200 ratio.” I have patients driving from over an hour away because it takes months on the waiting list to see a primary care doctor in their area, and now I am seeing veterans too, because we are more than 40 miles by road from the nearest VA hospital.

This article:Β  http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/ makes me laugh. The student says that 90% of family practice visits are probably coughs and colds. Uh, I would say that less than 5% of mine are. Half of my patients are over 65 and what I do is care for chronic disease with some acute disease thrown in. Diabetes, hypertension, coronary artery disease, rheumatoid arthritis, stage III renal failure, opiate overuse syndrome, depression, PTSD, and the average patient has 4-5 chronic diseases, not one. So the complicated ones have 9 chronic diseases. If they have walking pneumonia and diabetes and are 80, what was their last creatinine so I can adjust the antibiotic dose for their stage three renal failure? My oldest current patient is 98, has diabetes and still is out haying…. rural medicine is never ever boring and some days I think, oh, I would pay to see a simple cold. In the last two months one patient had a four vessel bypass, two have hepatitis C, one has hepatitis B and last month I found one with pertussis: whooping cough. And one has to go to the Big City to see the gynecologist-oncologist….

Rural family medicine is the ultimate generalist. I have to know a little bit of everything and know when to call and ask questions and who to call. Once I had an obstetrics patient with severe and confusing back pain after an epidural. I knew it was something peculiar because we could barely control it with opiates and her back exam was fine. I started calling specialists: ob-gyn didn’t know. The nurse anesthetist. My local internist. An orthopedist. A neurologist, the closest one 90 miles away. Then I got it: I called an anesthesiologist in Denver, 250 miles from where I was. He said it was an inflammatory reaction to the epidural medicine and to give her steroids, which would fix it. It did… but it was my being sure that I had something different on my hands and the stubbornness to keep calling until someone knew the answer….

A friend from college got a PhD in genetics and then went to medical school at the same time as I did. We talked when we picked our specialties. She chose pathology. I chose Family Practice. “Not Family Practice!” she said. “Why not?” I asked. “You can’t know everything!” she said. I said, “Well, no one knows everything. Put three top specialists in a room and they argue about the research. The trick is knowing what you know and what you don’t know.”

We need more primary care physicians and more rural family doctors. And it’s only getting worse.

http://www.aafp.org/about/policies/all/rural-practice-paper.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071163/
http://healthleadersmedia.com/content/COM-208773/Physicians-Offer-Insights-on-Practicing-Rural-Medicine.html
http://www.siumed.edu/academy/jc_articles/Distlehorst_0410.pdf
http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/
https://www.aamc.org/newsroom/newsreleases/358410/20131024.html
https://www.washingtonpost.com/news/to-your-health/wp/2014/05/22/how-many-patients-should-your-doctor-see-each-day/
This blog post helped inspire this article: https://theridiculousmrsh.wordpress.com/2015/11/03/why-i-hope-my-doctor-is-off-having-a-cup-of-tea-as-seen-on-the-huffington-post-yup-actual-huffpost/

The picture is some of the madashell doctors on our first trip stumping for single payer health care in 2009.

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Why I Hope My Doctor is Off Having a Cup of Tea (as seen on The Huffington Post. Yup, ACTUAL Huffpost!)

I have helped out in the ER when the doctor was running two codes simultaneously… the last time a person yelled at me for running late, I said, “Well, I had to call pulmonology, cardiology and infectious disease about my last person. How are you?” In the US, apparently primary care doctors running at burnout has risen from 40% to 50%. Not a good situation, so thank you for this post…..

theridiculousmrsh's avatarThe Ridiculous Mrs H

I recently wrote an article on the eight weeks I spent in the NHS, in the build up to having my tiny little Iris. It was the scariest time ever, and unfortunately I’m not very good at being funny when I talk about it! I was over the moon to find out that The Huffington Post wanted to publish it!

I’m so overwhelmed by the reaction I’ve received off the back of it from the amazing people in the NHS and their patients. Please, take a read, and share if you want, and as always I would love to know your thoughts on it!

Here it is….

The other day, I was in a hospital waiting room waiting for an ultrasound appointment. There was a couple next to me, and they were not happy. Apparently, as the whole waiting room were finding out: their doctor was running late. After…

View original post 1,796 more words

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Songs to raise girls: Down by the Salley Gardens

In 2009 my sister came to visit for spring break and our birthdays. We were born in March, five days and three years apart. I said that her birthday present was arranged: a recording session with me, her and my father, to record some of the family songs that we had been singing since birth.

My family had music parties in the 1960s on the east coast and when they were in college at the University of Tennessee. My mother had quit Cornell and my father had quit Princeton and they got married and went to the U of TN and I was born 9 months later. They were very poor. My mother said that she wanted to buy me a three dollar teddy bear but that they just couldn’t afford it.

They did not have a television. They were beatniks and admired On the Road. My father’s family all played instruments and sang. My mother had a much less trained voice but she had a prodigious memory and knew the fourth, fifth, sixth and all the verses of the folk songs. My father also sang classical music and had already sung at Carnegie Hall in his prep school chorus, Williston Prep School. He hated prep school. He had a full scholarship there and to Princeton because he scored perfectly on the early SAT test.

My parents refused to get a television until I was nine and my sister was six. So we sang.

My sister’s response to the birthday present: “Best Birthday Gift Ever.”

She had cancer and my father had emphysema. My mother had died in 2000. I was trying to capture their voices.

We recorded for two two hour sessions in a local in home studio. We made a list of songs and lost it on the way there. So we just took turns naming songs. Both my sister and my father play guitar. I brought kazoos, which we used on a round. We recorded each song once and in two days we recorded 36 songs.

I bought two more recording sessions at silent auctions, but we did not get to record again. And now they are both gone.

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My mother and father would sing “Down by the Salley Gardens” as a duet. He was a baritone and low bass. She was an alto. My sister and I sang her part in the recording.

Down by the salley gardens my love and I did meet;
She passed the salley gardens with little snow-white feet.
She bid me take love easy, as the leaves grow on the tree;
But I, being young and foolish, with her would not agree.

In a field by the river my love and I did stand,
And on my leaning shoulder she laid her snow-white hand.
She bid me take life easy, as the grass grows on the weirs;
But I was young and foolish, and now am full of tears

by William Butler Yeats in 1889

Listening to it, I miss my mother, my father, my sister. I miss singing with them. It was a love duet for my parents, and full of longing.

The photo is my parents, in about 1960.

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Causes of Death in the United States in 2012

When I first started doing annual physicals I sat down and looked at the top causes of death and then organized the counseling part of the physical around them: starting with heart disease and working down the list. I think of the annual physical as my opportunity to “MOM” patients and say “STOP DRINKING LIKE A FISH OR YOU GONNA DIE EARLY,” though perhaps with a little more diplomacy. Sometimes without much diplomacy at all.

The top ten causes of death in the United States in 2012 were heart disease, cancer, chronic lower respiratory diseases, stroke, unintentional injuries, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.

http://www.cdc.gov/nchs/data/databriefs/db168.htm#which_population

This is 2,543,279 deaths in 2012.

Let’s take the causes one by one.

Heart disease: This is number one. 599,711 deaths. 23.6% of total deaths all ages both sexes in the US in 2012. So that is where I start when I do the counseling part of a physical.

Let’s review heart disease risk factors:
hypertension
high cholesterol
family history
diabetes
kidney failure
lack of exercise
tobacco
alcohol
smoking other things…
illegal drugs
stress
obeisity
As you might guess, this part of the discussion can use up a lot of the visit….

Cancer: All the cancer deaths together are 22.9% of the 2012 total.
We can screen for a few cancers: lung cancer is now the number one killer for both sexes. A chest xray is useless for screening. There is a certain population of current or former heavy smokers where a screening CT is useful. No, I do not recommend a “screening full body CT”, that is crap. Yes, lung cancers do get picked up randomly when we do a chest film for some other reason.
We can screen for breast cancer, colon cancers, look for skin cancers, the prostate cancer screen is a counseling nightmare and I don’t recommend a PSA but will do one if the person wants and other cancers pretty much we have to watch for symptoms….stop smoking, ok? That’s what causes 70% of the lung cancer and breast cancer used to be number one in women but smoking made lung cancer beat it out….
If you want details about any screening test, go to the US Preventative Task Force site:
http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care

Chronic lower respiratory diseases at 5.6%: ok, smoking again. Emphysema and chronic obstructive pulmonary disease, AKA COPD. Asthma too. This article is fascinating, that third generation children of smokers in a polluted part of California are worse and have inherited genetic modifications than third generation children of non-smokers who live in a less polluted part of California. Lovely. I grew up in a two pack a day camel household and no wonder my lungs are tricky.

Stroke, also called CVA, cerebrovascular accident, at 5.1% and then there are TIAs, transient ischemic accidents, the stroke warning symptom.

What are the risk factors for stroke?
Oh, smoking of course
hypertension
high cholesterol
stress
lack of exercise
obeisity
blocked carotid arteries
blood clots
atrial fibrillation

Unintentional injuries at 5.3%, also known as accidents.

Deaths from prescription medicines taken correctly outstripped deaths by MVAs, motor vehicle accidents and guns in 2007. The CDC declared an epidemic of overdose deaths, but it’s just starting to creep into newspapers and public consciousness.

Here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The unintentional injury counseling list includes:
wear your seatbelt
don’t drive inebriated
don’t get in the car with inebriated drivers
check your smoke alarms
in the elderly, decrease fall risk. don’t stack stuff on the stairs.
wear a helmet if you bicycle motorcycle ATV rollarblade ski or invent some new way of getting on the Darwin list. Base jump, for example.
don’t take a lot of controlled prescription medicines or combine them with each other or combine them with alcohol: opiates with benzodiazepines with alcohol with ambien or sonata with barbituates and hello, the drug dealer is not your friend and tells lies: they are cutting the methamphetamines here with tricyclic antidepressants and barbituates and my long term cocaine addict patient was getting methamphetamines with benzodiazepines when he was paying for cocaine. Really.

Alzheimer’s at 3%

This is moving up the list. Fast. Everyone dies of something. Alzheimer’s patients live an average of seven years from diagnosis….And the recent article about Human Growth Hormone transmitting not only prions but Alzheimer’s is really interesting, implies an infectious cause.

Here: http://www.nature.com/news/autopsies-reveal-signs-of-alzheimer-s-in-growth-hormone-patients-1.18331

That was HGH from cadavers. I still would not take HGH made in a lab for “anti-aging” either. Nope, nope, nope.

We don’t know how to prevent Alzheimer’s but that is not the only cause of dementia and we’re still naming different kinds. Very frequently a brain CT or MRI says “decreased white matter” or “small vessel disease”, so there is a contribution from all of the heart and stroke risk factors that can do bad things to the brain with the top ones being: tobacco, alcohol, hypertension, high cholesterol, stress, lack of exercise, diabetes, illegal drugs, and so forth. Keep your brain active and busy.

Diabetes at 2.9%
Ok, it can make you more likely to have a heart attack. Also the biggest cause of blindness in US adults and the biggest cause of lower limb, yes, foot or leg amputation and the biggest cause of kidney failure in adults. Also if your legs are numb from uncontrolled diabetes, you don’t feel injuries and are less able to heal infections. And if blood sugar is high, there are lots of bacteria and especially staph and strep that LIKE high sugar.

influenza and pneumonia at 2.1%

Get Your Flu Shot. Really. And if you are 65 or older or you have tricky lungs or you have a tricky heart, get the pneumovax shot. The pneumovax protects against pneumococcal pneumonia ONLY, not all the colds or influenza or hemophilus influenza. And get your Tdap, because that stands for Tetnus, Diptheria, acellular Pertussis. Pertussis is whooping cough. It’s back. We’ve had three outbreaks in our county in five years. It kills babies under six months. They don’t whoop, they just stop breathing, apnea. Other people whoop, but even with antibiotics, they can cough for MONTHS. The flu shot usually gives 80% protection by two weeks after the shot. Only 80%, people say? Well, are you perfect?

Kidney disease at 1.8%

Causes: kidneys get worse as we age, for one thing.
diabetes
supplements and drugs: kidney failure is on the rise! Everything that we absorb and metabolize is metabolized by either the liver or the kidneys. Liver function can be perfect at age 100: that is, if it has not been trashed by alcohol, hepatitis B or C, drugs, supplements, mushrooms, whatever. Kidney function usually drops by age 80 and I am there calculating the function before I choose an antibiotic because you have to use lower doses in the over 80 crowd and the early kidney failure crowd. If you take ANY PILLS you should have a yearly test of your kidneys and liver function.
infection can hurt kidneys
inherited disorders

Suicide at 1.6%
40,600 deaths in the United States in 2013

Risk Factors http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

And for those who want in depth information, 15 leading causes of death by state:
http://www.cdc.gov/nchs/nvss/mortality/lcwk9.htm

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Chronic pain and antidepressants

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Quimper

Q is for Quimper in the Blogging from A to Z Challange.

I live on the Quimper Peninsula in Jefferson County, Washington, USA. The Quimper Peninsula is a small peninsula jutting up from the northeastern corner of the Olympic Peninsula. So, a peninsula attached to a bigger peninsula.

We are surrounded by water. When I first moved here I was confused. I am from the east coast of the US. So, the ocean was to the east. Here on the west coast it is west: except that where I live, the Salish Sea is north and east and south. The Quimper Peninsula runs southwest to northeast and ends at a lighthouse. I can stand on the beach at the lighthouse and look over the Salish Sea and see mountains. It took me a while to get oriented, because I can see the Olympic Mountains looking over the water or the Cascades: Mount Baker, Glacier, Tahoma.

The Quimper Peninsula is named after Manuel Quimper, a Peruvian born Spanish explorer and cartographer. He contributed to the charting of the Strait of Juan de Fuca in the late 1700s. Until I wrote this post, I had not read about him.

Our thin rural phone book for Port Townsend and Port Ludlow lists five Quimper named businesses:

The Quimper Inn, a bed and breakfast. Our town had a boom in the 1860s-1880s and the architecture is still here. There are wonderful old houses and downtown.

Quimper Mercantile, a community started and owned store.

Quimper Sound, a quite fabulous local music store, albums and CDs.

Quimper Unitarian Universalist Fellowship, a church.

And lastly: Quimper Family Medicine, my family practice clinic!