admit deny

For mindlovemisery’s prompt: opposing forces. The prompts are admit/deny and presence/absence.

The pairs bring up my current sadness right away. I am struggling with the realization that we have a pervasive legal substance that works at the opiate receptor, is all over the US, and I have to send out urine tests for ALL of my chronic pain and opiate overuse and anyone on any controlled substance. You say, “but it’s legal”. I say, “Overdose and death risk. I can’t ignore it.” Here is the resulting poem.

admit deny

admit to yourself you deny your addiction
the presence of the drug means the absence of the one I love

 

Container dream

I dream I am at a concert in a park. Or some very big event. With my significant other. It is a beautiful day, the sun is shining, the grass is green, there are rolling hills and trees. People are arriving.

There is a gasp of horror. There is a large box, like the hold of a ship. We hurry to look in: there are three open containers down inside, tops removed. They are full of children. Smuggled? Immigrants? The containers are surrounded by water. My significant other and I drop our things and climb down the long hold ladder into the water, which is cold, filthy, and comes up to my thighs. I’ve kicked off my sandals. We are wading to the containers. An ICE agent in a black uniform, bullet proof vest, belt with tools and guns, and riot helmet, blocks me and says, “You have to be wearing shoes to help.” He is handing out plastic stretchers. He can’t see my feet. Yes, I know it’s dangerous and my feet could get cut, but this is probably sewage and dangerous even with shoes. We should really be in hazmat gear but the kids could be dying. I just look at him, silent, and he hands me a stretcher.

Enough people have come forward, into the water, that all the kids have been placed in one of the containers. None of them are dead. They are being lifted out one by one, to ambulances. Now the hold is surrounded by rubberneckers. I climb out and find my purse and camera and shoes. I am grateful no opportunist has stolen them. The ICE agents are telling people to back off and give them room to work. The news crews are there and a Washington State politician says, “This is Washington State, we will take care of these children, we will not see them separated and incarcerated, I will see that they are returned to their parents.” Good luck, I think, but at least there are tons of witnesses and cameras and news crews.

I need to find somewhere to scrub my legs down with soap and to find my significant other. It’s getting more crowded.

I wake up.

And what I notice is that the water did not stink and was not full of lumps of floating excrement. As I wake I hope that I won’t catch something horrible and die….usually my dreams have full sound, color and smells too. I wonder where the children were from, and why, and whether they had some sort of sanitation….

Tobacco Use Disorder

With the DSM-V, there is no longer a separate diagnosis of Opioid Dependence and Opioid Addiction. The two are combined into Opioid Use Disorder. Opioid Use disorder can be mild, moderate or severe. And all of the addictive substances have the same list. So here is Tobacco Use Disorder.

According to the DSM-5, there are three Criterion with 15 sub features, and four specifiers to diagnose Tobacco Use disorder. Use of tobacco products over one year has resulted in at least two of the following sub features:

A, Larger quantities of tobacco over a longer period then intended are consumed.

1. Unsuccessful efforts to quit or reduce intake of tobacco

2. Inordinate amount of time acquiring or using tobacco products

3. Cravings for tobacco

4. Failure to attend to responsibilities and obligations due to tobacco use

5. Continued use despite adverse social or interpersonal consequences

6, Forfeiture of social, occupational or recreational activities in favor of tobacco use

7. Tobacco use in hazardous situations

8. Continued use despite awareness of physical or psychological problems directly attributed to tobacco use

B. Tolerance for nicotine, as indicated by:

9. Need for increasingly larger doses of nicotine in order to obtain the desired effect

A noticeably diminished effect from using the same amounts of nicotine

C. Withdrawal symptoms upon cessation of use as indicated by

10. The onset of typical nicotine associated withdrawal symptoms is present

11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms

Additional specifiers indicate the level of severity of Tobacco use disorder

1. 305.1 (Z72.0) Mild: two or three symptoms are present.

2. 305.1 (F17.200) Moderate: four or five symptoms are present.

3. 305.1 (F17.200) Severe: Six or more Symptoms are present

(American Psychiatric Association, 2013).

from: https://www.theravive.com/therapedia/tobacco-use-disorder-dsm–5-305.1-(z72.0)-(f17.200)

We have much more stigma attached to Opioid Use Disorder, but list for Tobacco Use Disorder is the same. Most chronic pain patients on long term opioids qualify for at least mild Opioid Use Disorder. UW Telepain says that if they only have withdrawal and tolerance, then it is questionable if they qualify. They also have said that “we don’t know what to do with patients with mild opioid use disorder”.

I find our culture peculiar. People get accolades for saying “I am quitting smoking.” or “I am a recovering alcoholic.” But it’s not ok to say “I am a recovering opioid addict.” People will shun you. Demonize. Gossip. It’s all addiction, so we should stop the demonization and stigmatization and help people and each other.

The photograph is not a brain. I took this about a month ago: it’s a brain size mushroom that was in the church lawn…

Why can’t I just call for a referral?

Why, you say, do you need to SEE your doctor for a referral? It’s so stupid!

Multiple reasons:
1. Triage.
2. Scarce resources.
3. Your primary care may be able to handle it.
4. The specialist only wants to see people that they can help.
5. You may think that you and Dr. Google have it figured out, but Dr. Google sucks.
6. For physical and occupational therapy, it has to do with caution and malpractice insurance.

Let’s go through them backwards.

6. People call for a referral to physical therapy. I say I need to see them. No, I can’t make a diagnosis through the phone. Arm hurts is rather vague. The person says their insurance does not need a referral. But then the physical therapist wants one: why? Well, my malpractice outranks the physical therapists, so to speak. If the therapist sees you without your doctor examining you and something happens… yes, things have happened.

5. Dr. Google. You’ve read extensively and you know exactly what is going on and you just need the referral. No, you have not gone to medical school or residency. Every quack who can say anything even faintly convincing now has a website. Dr. Google sucks. There are very very rare exceptions to that…

4. The gastroenterologist does not want to see your bladder problem. The neurosurgeons hate seeing the people that will not benefit from back surgery, but they have to because the back pain patient doesn’t believe me, so the patient has to hear it from the surgeon. The patient thinks I am “gate keeping” them from the specialist. I’m not.

3. Primary care learns to handle a lot of things. One frequent referral is a postnasal drip, to the Ear Nose and Throat specialist. I recommend trying an acid blocker first. The person doesn’t believe me. “I don’t have heartburn.” I sigh, and do the referral. $450.00 later, the ENT has put the scope through their nose and put them on an acid blocker.

2. Scarce resources: We had 8 neurologists on the Olympic Peninsula for about 450,000 people. We are down to two. I called one for a complex stroke-that-wasn’t and had to do a series of MRI/MRA studies looking for specific things. It was a vertebral arterial bleed. Rare. I called the neurologist back and he said, “Send them to the other one. I am swamped.” He is in the larger population area and two others quit. The rule is sickest is seen first…

1. Triage. What is wrong, what are we worrying about and how sick is this person? If they are really sick I will call the specialist to ask for recommendations, or which test to do, or see if they need to be seen within a short time. I am not going to interrupt the specialist unless I think it’s really necessary! That would burn through my carefully built credit with them! And I have had a person come in for a new patient visit for a “lung problem”. I call the specialist, get him seen and he has a heart bypass….

0. And I am a specialist too. I am a Family Practice physician, board certified and board eligible, three year residency. The internist, the pediatrician, we are all specialists and all special.

fraud in medicine: navigating your failing healthcare system

Navigating health care in the United States is challenging and challenged. Currently the 800+ insurance companies, each with multiple “products”, the 500+ electronic medical records that don’t talk to each other, the increasing volume of information and the decreasing number of physicians make getting care very challenging. Here are some steps to help you navigate.

1. Get your records and keep copies.

Get the disc of any radiology studies: MRI, xray, CT scan, echocardiogram. Keep them. Hand carry to your visit with the specialist. Yes, I know your doctor said they’d be sent and I know the specialist’s office said they’d get them, but I have two friends so far this week in two days who traveled 2 hours or more to a specialist who DID NOT HAVE THE STUDIES. Do NOT give your only copy to the specialist. Demand two. Either get them on different days or just pay for the second disc.

A clinic closed in our area a year ago. It was in three counties, 3400+ patients. The physician owner was not paying the bills, including the electronic medical record. We couldn’t get records, the emr company wouldn’t release them. Gone. Thirteen people called to be new patients with me the day the clinic closed and we took five new patients a week for 6 months. You need a copy of your records.

2. In the specialist’s office or ER, do NOT give your records to the receptionist.

Hand them to the physician only. Hand them copies, you keep copies. “When will you be getting back to me?” That is, if it’s two hundred pages of complicated records, when does the physician think they can read (some) of them? The real truth is that WE CANNOT READ ALL OF THE OLD RECORDS. We don’t have time. We have to sleep. We read what we can and there are MOUNTAINS of old records that we haven’t read. I have files of old records and I pull them for visits so we can look up specific things. I have asked patients to go through and find specific things: find me the MRI report of your back.

Because what is really happening in many offices is that the information is being scanned but not read. Truly. I think this is dangerous. I had a patient who had five specialists and me. I was sending updates to his rheumatologist, with letters, asking questions and not getting a word back. Finally the patient went for the two hour trip to see the specialist, who called me: “I had not read any of your notes! I didn’t know what was happening!” I saw RED. Oh, so my letters and the ER notes and the other specialist notes that I faxed to you MYSELF about a very sick, very complicated medicine WERE NOT READ? I wanted to scream at her, but I didn’t. I just said, “We really need your help and I have been trying to keep you informed.” Through gritted teeth. Then later I kick and hit my heavy bag. And at that point the specialist was finally helpful. It still makes me furious just to think about it, so I have to work on forgiveness once again.

In my office, if a physician (me) has not read it, it has not been scanned. There will NOT be surprises in the scanned chart. The unread old records are filed alphabetically and when I have a time turner, I will have time to read them all, right? And then in a visit, the person asks if I got their mammogram report. I have to LOOK, because I sign off on about a billion different pieces of paper a day and I really don’t remember the names of all the people who had normal mammograms. I don’t try to remember that: I know who has an abnormal one, because I am worrying about them.

3. Make a record trail that you can quote.

When you call the physicians office, get the name of each person you speak to. Write it down. Have them spell it. Ask how soon you will be called back. Ask what you should do if you do not get a call back. (That being said, every physician has to prioritize the calls. It’s sickest first, not first come first served. If your call really is an emergency, then you should be in an ambulance, not calling your doctor.)Our local mental health was in such disarray, understaffed, underfunded, that my instructions to non-suicidal patients were: “Call every day, be polite, and call until they make you an appointment. Do not wait for the call back. Call daily, they just don’t have enough staff.”

If you fax them the missing notes, keep a copy of the fax proof. Call after your fax the missing records. Ask if they received them and then write down the name of the person you spoke to, date and time. I put a computer message in the chart for 99% of the phone calls I have with patients. I may miss 1% because I get interrupted or a really sick patient arrives or another phone call or whatever. Ask when the physician or his assistant will be calling you back about the records or better yet, make an appointment: “He did not have the records, so I would like an appointment as soon as possible now that he has them.” This forces your physician to look at the old records, because the patient is coming in. I do not read old records before a new patient shows up. I used to, but then people no show for a one hour new patient visit and I feel used, abused and grumpy. So I don’t touch the old records until you show up. After two one hour new patient no shows we tell the person they need to find another physician. Two strikes on the new patient visit and they are out.

4. Hospital.

If a person is really really sick, family or friends should be there. Ask questions. Who is each person who comes in the room? Do they have the clinic notes? Don’t assume they do, I am not on our hospital’s EMR because it costs 2 million dollars. The inpatient hospitalist doctors almost never call for my notes. I fax my notes anyhow and call them, but the information gap is BIG ENOUGH TO DRIVE THE MOON THROUGH. Really. I am sorry to burst the electronic medical record bubble, but we have 500ish different EMRs in the US right now and they do not talk to each other, so every patient arrives accompanied by 2 years of paper records (or more), 200 pages or more. I joke that they need a bigger doctor because the paper is too heavy for my 130 pounds. And many many times, the hospital medicine list is wrong. It is old. It’s out of date. The person is sick as hell in the emergency room and they don’t remember that their lisinopril dose was changed three weeks ago. One person in the room with the sick person and keep a notebook and write down what the physicians and nurses say, time, date. Then if they start contradicting each other, ASK.

5. In clinic

Give your doctor the whole list right away: my foot hurts, my chest is really bad when I try to run up the stairs, there’s this thing on my arm and is my cholesterol too high? Don’t discuss one thing in detail and then bring up the next. I have long visits, but I can’t do justice to that list in one visit and I have to prioritize. This requires negotiation: the chest pain has my attention. You may be focused on your foot, but the number one killer is heart, so your doctor will worry about your heart first.

If the doctor asks you to bring in all your pills, bring them all in. There are three different types of metoprolol and five strengths of each. Do you know the type and strength of every drug? I want to see your vitamin bottles because vitamin B1 can cause neuropathy from too high doses and yes, they can sell high doses. I want to see the supplements: why are you taking bovine thymus/testicle pills? By the way, if the doctor actually looks at the supplements, keep that doctor. Most don’t.

6. Be careful out there. Good luck.