Practicing Conflict II

Practicing conflict II

In Practicing conflict, I wrote about practicing conflict by arguing different sides of a topic inside my head. I wrote that I don’t fear conflict and have learned to enjoy arguing with myself. I am a physician and physicians argue all the time.

What? No they don’t. Well, the doctor persona does not argue with the patient much. Some doctors give orders to patients, others try to negotiate, some try to convince. But behind the scenes, doctors are more like the Whacky Racer Car with the Cave Guys, running with their feet and hitting each other with clubs.

In residency in Family Practice at OHSU in Portland, Oregon, I start on General Surgery during internship. This is in the early 1990s and there was not much in the way of “disruptive physician” rules. I have to cover Trauma and Plastic Surgery and General Surgery at night on call. The resident is present but I get paged first for patients on the floor. I learn that I should go to all Trauma pages in the emergency room. If I know what is happening with the new Trauma patient, it’s a lot easier to handle the phone calls for more drugs and so forth. Also, the resident is less mean to me.

We attend the Trauma “Grand Rounds”. These are unreassuring to a new intern. A resident presents a trauma patient, giving the history in the accepted formal order. The Faculty Trauma Surgeons interrupt, disagree with management of the patient and yell. They yell at the resident and at each other. The upper level residents yell too, being well trained. The Trauma Surgeons do not agree with each other. They are inflammatory and rude. I am shocked initially: medicine is not a cookbook, is not simple and it appears that it is a controversial mess. It turns out that medicine IS a controversial mess.

There is not as much yelling on the next rotation. At that time Trauma Surgeons yelled more than any other set of doctors that I ran across. They yelled in the ER, at each other, at the staff, at the nurses, at the residents. The culture has changed, I suspect, but that’s how it was then.

I take Advanced Trauma Life Support as a third year resident. The Trauma Surgeons at OHSU helped write the course. They don’t agree with it. On some questions the teaching Surgeon says, “The answer to this question is (c), “ followed by muttering loudly, “though I totally don’t agree with that and I would do (b).” Another Trauma resident or surgeon then might start arguing with him, but they moved on pretty quickly, to teach the current agreed best practices in the book. Which change every few years. Great.

Years later (2009) I join the Mad as Hell Doctors, to go across the US talking about single payer. They are a group from Oregon. Physicians for a National Healthcare Program are a bit cautious with us the first year: we might be whackos. We have an RV with our logo and we have a small fleet of cars and what do you think we do in the cars? We argue. Or discuss. Or whatever you want to call it. We spend the driving dissecting issues and how to present things best and tearing apart the last presentation and rebuilding our ideas. The group does 36 presentations in 24 days. Each presentation takes an hour to set up, two hours to do and another hour to break down and debrief. We get more and more exhausted and cranky and um, well, argumentative, as the trip proceeds. Even though I think of the Whacky Racer Cave Guys running with their feet and bonking each other with clubs, this is the most wonderful group of doctors I have ever been with. A common goal that we all want to get to, discussing and disagreeing on strategy all the way! I feel closer to those physicians in a week then I feel to any of the physicians that I’ve worked with for the last 9 years in my small town. Conflict with a common goal.

Doctors are TRAINED to argue, even with themselves, to document every decision in the chart with reasons why they have reached that decision. And that they have thought about all of the reasons for say, a low potassium, thought of every possible cause and worked their way through testing. The testing always has two strands. One strand is rule out the things that could kill the person NOW, even if rare. The other strand is what is common? You have to think about both at the same time, always. And argue with yourself about which tests should be done, in what order, what is most important, how do you treat the person while awaiting results, and have I missed anything? And if we aren’t sure, we call another doctor, run it by them, wait for them to shoot holes in our logic or to say, no, I can’t think of anything else.

We can deal with conflict. We must deal with conflict. The world is too small not to deal with conflict, with disagreements, with different viewpoints and positions and ideas. If doctors can do it every single day at work, then everyone else can too. Trying to see all the positions and possible diagnoses saves lives in medicine. We need to extrapolate that to everything else. Try to see other positions, try to understand them, to respect them. We can and we must.

Blessings.

Here are the Whacky Racers:

And Madashell Doctors blog: http://madashelldoctors.com/category/uncategorized/page/3/

For the Ragtag Daily Prompt: discuss.

The photograph is from my clinic once we had stopped seeing patients and were selling everything. Mordechai was our clinic skeleton, made of plastic, from China. This was in January 2021.

Practicing Conflict

An essay from my church talks about the writer avoiding conflict, fearing conflict and disliking conflict. This interests me, because I do not avoid conflict, I don’t fear conflict and actually, I like it. Our emeritus minister once did a sermon in which he said that when you are thinking about two conflicting things at once, that is grace. I have thought about his words many times, especially when I am not in agreement about something.

Does this interest in conflict mean I fight all the time? Well, sort of, but not in the way you think. I don’t fight with other people much. I fight myself.

What? No, really. Most topics have multiple sides. Not one, not two, but many. Like a dodecahedron or a cut gem. Hold it up to the light, twelve sides, each different. I argue the different sides with myself.

I learned this from my parents. My parents would disagree about something, they would discuss or argue about it, and then they would bet. Sometimes they bet a penny, sometimes a quarter, sometimes one million dollars. Then one of them would get up and get the Oxford English Dictionary, or the World Atlas, or some other reference and look it up. This was pre-internet, ok? 1970s and 1980s.

Sometimes my parents would even pay each other. The penny or quarter. My father spoke terrible French and my mother had lived in Paris for a year after high school, so he could get her going by insisting that his French was correct. It wasn’t. Ever.

There were other arguments in the middle of the night that were not friendly and involved yelling, but the daytime disagreements were funny and they would both laugh.

Once my sister is visiting after my mother has died. My father is present. My father, sister and I get in a three way disagreement about physics. I’m a physician, my sister was a Landscape Architect and my father was a mathematician/engineer, so we are all three talking through our hats. However, we happily argue our positions. Afterwards, my gentleman friend says, “That was weird.” “What?” I ask. “That was competitive and you were all arguing.” “It was a discussion and we disagreed.” “I won’t compete.” “We let my dad win, because it makes him happy.” “That was weird.” “Ok, whatever.”

My gentleman friend is also shocked when my teen son challenges me at dinner. My son says, “I am researching marijuana and driving for school and there isn’t much evidence that it impairs driving.”  I reply, “Well, there is not as easy a test as an alcohol test and it was illegal, so it has not been studied.” We were off and having a discussion.

Afterwards my gentleman friend says, “I am amazed by your son bringing that up. We weren’t allowed to discuss anything like that at dinner.” I say, “We pretty much discuss anything at dinner and both my kids are allowed to try to change my mind. About going to a party or whatever.” He shakes his head. “That is really different.” “Ok,” I say.

This habit of challenging authority, including adults, did not go over well when my son was an exchange student to Thailand. It did not occur to me to talk to him about it. He figured it out pretty quickly.

Back to my internal arguments. If I take a position, I almost immediately challenge it. I think of it as the old cartoons, with the angel on one shoulder and the devil on the other. The devil will make fun of things and suggest revenges and generally behave really badly. The angel will rouse and say, “Hey, you aren’t being nice.” Then they fight. The internal battle very quickly becomes comic with the two of them trading insults and bringing up past fights and fighting unfairly. When it makes me laugh inside, I can also be over the driver who cut me off, or someone who spoke nastily, or whatever. My devil is very very creative about suggested revenges. When the angel says, “You are meaner than the person who cut you off!” I am over it.

When I was little and disagreeing with my family, my sister could tell. “You have your stone face on!” That meant I was attempting to hide a feeling, especially fear or anger or grief. Siblings and family are the most difficult because they can read us and see through us like glass. My physician training also teaches control of feelings. I have sometimes wanted to grab a patient and scream “Why are you doing this to yourself?” but that really is not part of the doctor persona. I am doing it inside, but I can put it aside until later. Then the devil goes to town! And the angel tries to calm the devil down.

Maybe we all need more of this skill. Pick a mildly controversial topic. Argue one side of it. Then switch positions and argue the other side. Go back and forth until it gets ridiculous. Let each side get unreasonable and inflammatory and annoying. This can play in your head and not on your face. Once you can do a mild topic, move on to something a bit more difficult. If you only know the arguments on your side, read. You can find the other side, the internet is huge. Start gently.

A friend says, “You always argue about things.” I say, “I prefer to think of it as a discussion.” “You always take the other side.” “Well, it interests me. And if there is no one to discuss something with, I discuss it with myself!” “Weirdo,” says the friend. I think he’s jealous, really I do. Don’t you?

Care bare? No, Care Barrier.

My cardiologist told me to go to the Mayo Clinic six months ago.

I saw him last week and he wanted an update.

I said, “I filled out a request for a visit and my primary care referred me, but Mayo Clinic never called.”

He replies: “I will refer you.”

A week later I get a call from Mayo Clinic. But I do not have an appointment yet because

  1. They are booked out until November 18th. I am advised to “call daily” to get my appointment. They open up a week at a time, but don’t say when. A new meaning to “maybe you’ll get lucky”.
  2. They do not take my insurance and want a $5000 deposit prior to seeing me. I can fill out paperwork to ask for patient assistance. This would be the fifth hospital system in which I have filled out that paperwork. I have had to do it for four other places. The paperwork is different for each one and some even want a copy of my taxes. Do you think it’s secure? Of course it isn’t.
  3. I have to go in person to Minnesota, so add a round trip plane ticket to that $5000. They may do tests while I am there, so I don’t know how much of the $5000 I would get back. If any.

At the moment this seems insurmountable, but I will keep chipping away at all the insane barriers and paperwork. What a stupid medical system the US has, right?

We still need single payer and medicare for all. There would be one set of patient assistance papers, not five.

Vape

First, the definition of vapor:

noun

  1. The gaseous state of a substance that is liquid or solid at room temperature.
  2. A faintly visible suspension of fine particles of matter in the air, as mist, fumes, or smoke.
  3. A mixture of fine droplets of a substance and air, as the fuel mixture of an internal-combustion engine.

So vaping is smoking. It can be called vaping, but that is to trick us into thinking that it is not smoking, that we are not sucking chemicals into our delicate lung tissue. We only have one set of lungs. Lungs are like a tree, either the roots or the leaf parts upside down. Air is drawn in by our muscles expanding the chest and diaphragm, down the trachea, the bronchi, the bronchioles and at last to the alveoli, where tiny veins wrap each alveoli, trading carbon dioxide for oxygen.

I think of smoking as every cigarrette distroying an alveolus.

Vaping too, vaping is smoking. The nicotine is suspended in a solution and the vaporizer heats up until it is in vapor form. I started reading about vaporizers at least a decade ago. There were over 500 different types, mostly made in China, and there are all sorts of solutions. I was horrified to read that ethylene glycol was one of the solutions that held nicotine. When a dog drinks antifreeze, ethylene glycol, it is poisonous to the brain. Does anyone think that we should inhale smoke with antifreeze and nicotine in it? Really?

There is no control of what is put in the solutions. We don’t know what they will do long term but we know that nicotine is addictive and damages the lungs. Some of the vaporizers get so hot that the metal is also vaporized. Heavy metals are clearly bad for the lungs and poisonous as well.

Here is an article from the U of Colorado Medical Center with further reasons NEVER to start vaping. Because vaping is smoking: don’t let the term fool YOU. 4 reasons why you should stop vaping.

For the RDP: vapor.

part time

I only dress like this part time.

#outfitsinappropriateforwork

A friend took this with my camera at my request. Thank you, friend!

For the Ragtag Daily Prompt part time.

Defiance

Ok, this is a beautiful and romantic song, and yeah, George Strait is pretty.

And then there’s the Offspring. Singing Self Esteem. Guess which I like better.

The Offspring: defiance and singing about all sorts of things that we don’t talk about: “The more we suffer the more we really care!” Some of my patients needed to listen to this song. Often the mom, with a spouse and three children, who was taking care of all of them but not herself. “Who takes care of YOU?” I would ask. “No one,” some moms would say. “Look. There are FIVE people in your family. You are one of them. You deserve the same level of care that the rest of them are getting. I want you to include yourself in the people you take care of.” “BUT” “NO BUTS. If you don’t, then you are setting expectations for your children: the boys that a wife will take care of them and the girls to be walked on. Is that what you want?” “NO.” “Change it.” They often would, slowly but surely.

And The Offspring are further my heroes because of this song: Opioid Diaries. Ok, a punk band telling opioid overuse people to get help. MY HEROES! Thank you Offspring!!! It’s not easy to watch but wait until the ending and what if offers. I treated opioid overuse for the last 12 years in my small family practice clinic along with everything else: diabetes, hypertension, whatever. I never felt threatened or frightened, but some of that is because I grew up in an alcohol family. I recognize addiction. Reminding my of my parents is not a good sign. And I had to learn boundaries at home first. This is an uncomfortable video to watch but to me it is beautiful, because it offers hope.

Why I hate insurance companies: 1

I had cobra from my job in 2009 and the insurance company refused my bills. Not one bill. Not once. EVERY BILL EVERY TIME: 1. my healthcare 2. my son’s healthcare 3. my daughter’s healthcare 4. my daughter’s orthodontia 5. my dentist 6. my son’s dentist. I had to call EVERY TIME to get them to pay. Calling an insurance company takes 25 or 30 minutes, right? Eventually I asked for customer service who first said it was my fault because “you probably paid the bill late”. I said, “No, I was on time every month.” Then customer service wouldn’t call me back. I finally called their COUNSELING HOTLINE, since it said I would be “paid” $30 to get counseled, and said, “MY LITTLE SISTER IS DYING OF BREAST CANCER AND THE THING THAT IS MOST STRESSING ME OUT IS YOUR INSURANCE COMPANY WON’T PAY THE COBRA BILLS AND I HAVE CALLED CUSTOMER SERVICE OVER AND OVER AND THEY WON’T CALL ME BACK. HOW ABOUT YOU COUNSEL ME HOW TO DEAL WITH THAT!” And I cried. I got a call back from the head of customer service saying “Oh, it’s a computer glitch and we had you misfiled. We have fixed it.” They “misfile” people all the time, or drop patients if they get sick, or say the person didn’t pay on time. I HATE INSURANCE COMPANIES. Anyhow, be warned that insurance companies are there to earn money and will try to avoid paying you in all sorts of ways, including ways that are illegal.

We need single payer healthcare, medicare for all. If we all have healthcare, think of how many small businesses would start up. And why don’t we have single payer healthcare? I think the big corporations don’t want it.

Physicians for a National Healthcare Program: https://pnhp.org/

Medicare for all: https://medicare4all.org/

And my dear friends not on the road any more: http://madashelldoctors.com/

Who is the man in the photograph? I don’t know. This is an old tintype. They came from my Great Aunt, Esther White Parr, married to Russel Parr. Perhaps they are Parrs, because my Uncle Rob did not know any of the people in the four tintypes I have. My sister and I used them for portraits in our china doll houses. I hope he is not the CEO of an insurance corporation, but then, all the white collar white men tried to dress that way then.

I am the princess

I woke this morning thinking about a poem my sister wrote, titled I am a princess guarded by dragons snorting and grumbling and rumbling in wagons.

I am the princess guarded by dragons snorting and grumbling and rumbling in wagons

I am the princess guarded by dragons
snorting and grumbling and rumbling in wagons
I am the princess surrounded by briars
with wretchedly nasty folk starting briar fires
I am the princess with long, tangled hair
I cut it myself and I climbed down from there.

I am the princess, asleep ’til a kiss
woke me, he shoke me, all after was bliss
I am the princess who sat at her wheel
spinning, my fingers bled, hating the feel
I am the princess for whom you fought wars
Raggedly, jaggedly, murderous spars.

I am the princess, a wildvirginqueen
commanding with glory that none had foreseen
I am the princess who made wild things grow
I fought for my daughter, in winter below

I am the princess, I wore a great gown


Now cowboy pjs, I’d rather dress down.

by Christine Robbins Ottaway

________________________________

I did not want to be a princess when I was a girl. It seemed like a dead end career. The happiest day of a girl’s life was when she got married and what happened after that? Well, in the Disney animated movies, all adult women were either evil witches or evil stepmothers, or dead in childbirth. Until recently there were no live adult women on the throne who were not evil. And certainly the Queen in Frozen II has been attacked mercilessly by the Internet for being a woman without a man. Perhaps it would be okay if she were named Elizabeth.

I wanted to be a superheroine, not a princess. A secret identity was great and Spiderman had just as much angst as I had. I could be myself AND a superheroine. Princess seemed impossible and you had to be nice all the time and you had to talk to mice or spin straw into gold or be the daughter of a king. I did not want it.

Once I went to the Unitarian Church and my minister gave a sermon on each of the four types of Unitarians. That day was about mystics. I thought “Mystics, what hooey!” but by the end of the sermon I thought, oh, I’m a mystic. And a secret romantic. How exactly do I square that with my refusal to have anything to do with Princesses.

My sister was much more comfortable with the Princess Archetype than I was. I wanted a career that would support me and children, because even if my wedding was supposed to be the happiest day of my life, I still noted that half of marriages ended in divorce. And what about men? Almost no one celebrates the virgin male and I don’t think I’ve ever heard anything about marriage being the happiest day of a man’s life. What is the story there?

My version is titled: I am the princess

I am the princess guarded by logic
By science, degrees and words pedagogic
I am the princess staying in school
seeming obedient to misogynist rule
I rack up a degree, residency next
study the landscape, study the texts

I am the princess who longs for a kiss
various frogs taste worse than horse piss
I am the princess flaying a man
who was already dead, to learn what I can
I am the princess, no wars fought for me
I fly under the radar, no one can see

I am the princess, perhaps I’m a queen
hide in a small town, nearly unseen
Treating my people while staying awake
Try to avoid being burned at the stake

I was a princess hiding from most
raising my offspring, I’d rather not roast

__________________________________________

The photograph is from the Great Port Townsend Bay Kinetic Sculpture Race and is not me or my sister.

My sister’s blog: https://e2grundoon.blogspot.com/2009/01/chemo-not-in-vain.html

foxglove

The source of digoxin and digitalis. I am interested when people tell me they don’t take prescription medicines and that they only take “natural” medicines. Meaning pills. Pills do not grow on trees or bushes and are made by human beings. How exactly is the person defining “natural”?

My father said that anything a human could think up was “natural”. “Though that does not mean safe.” Think wingsuits and basejumping.

Digoxin and digitalis are used less than in the past, because there are many other medicines to choose from to control heart rate. However, they are still used because digoxin is one of the very few rate controlling medicines that does NOT lower blood pressure. Most of the others do lower blood pressure. When nothing else works or is tolerated, the cardiologist may sigh and say, ok, start digoxin. It is a tricky medicine because levels that get too high are toxic and the dose is different for each person and the dose must be lowered as kidney function changes with age. We still use it, though.

About one third of prescription medicines originate from a plant source like this, where the plant actually makes the active substance. Plants and animals and humans evolved together. We have deer all over town and they do not eat the foxglove. They love roses but stay away from foxglove.

I am seeing advertisements for a book to make your own medicines at home. I have not bought it. I would stay away from any recipe with foxglove: I want a lab to test to get the dose exactly right.

For Cee’s Flower of the Day. Heh, it turned into an essay of the day too. Wordy, wordy, wordy.