support

Back to San Antonio. I loved the varying bridges over the River Walk. Each has a different design. Some have birds nesting and others are not as preferred. The bridges have multiple designs and supports and the water is always changing. Walking outside renews me because the world changes all the time, changes of fall now at home.

Update on PTSD 2017: hope!

I have just spent a week in San Antonio, Texas at the AAFP FMX: American Academy of Family Physicians Family Medicine Experience.

Whew. Long acronym.

However, I attended two programs on PTSD. One was a three hour offsite one put on by the U. of Texas Health Sciences Department of Family Medicine. The other was a one hour program about active duty military and PTSD.

The biggest message for me is HOPE. Hope for treatment, hope for diagnosis, hope for destigmatization, hope for remission. I am not sure if we should call it a “cure”. Once a diabetic, always a diabetic, even if you lose 100 pounds.

In medical school 1989-1993 I learned that PTSD existed but that was about it. There was no discussion of medicines, treatment, diagnosis or cure.

Ditto residency. I learned much more about psychiatry reading about addiction and alcoholism and Claudia Black’s books then I did in residency.

Fast forward to 2010, when I opened my own clinic. I worked as a temp doc at Madigan Army Hospital for three months.

The military was aggressively pursuing treatment and diagnosis of depression, anxiety, PTSD and traumatic brain injury. I worked in the walk in clinic from 6:30 to 8:00 four days a week. Every walk in had to fill out a screen for depression. They were trying to stem the suicides, the damage, the return to civilian life problems and addiction too. They were embedding a behavioral health specialist in every section of the military. I was amazed at how hard the military was working on behavioral health.

In 2010 I took the buprenorphine course, which is really a crash course in addiction medicine, at the University of Washington Med School. I took it because it was free (I had just opened a clinic) and I thought we were as a nation prescribing WAY too many damned opioids. Yes! I found my tribe!

This gave me a second DEA number, to prescribe buprenorphine for opiate overuse, but also hooked me up with the University of Washington Telemedicine. I presented about 30 opiate overuse problem patients (anonymously, there is a form) to the team via telemedicine over the next year. The team includes a pain specialist, addiction specialist, psychiatrist and physiatrist. They do a 30 minute teaching session and then discuss 1-2 cases. They often do not agree with each other. They reach consensus and fax recommendations to me. The Friday addiction one was shut down and now I present to the Wednesday chronic pain one.

But, you say, PTSD? Well, chronic pain patients and opiate overuse patients have a very high rate of comorbid psychiatric diagnoses. It’s often hard to sort out. Are they self medicating because they have been traumatized or were they addicted first and then are depressed/traumatized and anxious? And what do you treat first?

There was an ADHD program at this conference that said we should deal with the ADHD first. One of the PTSD courses said deal with the PTSD first. The thing is, you really have to address BOTH AT ONCE.

Tools? PHQ-9, GAD-7, PCLC and there is an ADHD one too. These are short screening tools. I don’t diagnose with them. I use them to help guide therapy along with the invaluable urine drug screen. Love your patients but verify. That is, the chronic pain patient and the addiction patient tell me the same thing: but one is lying. I don’t take it personally because they are lying to themselves. Also, studies have shown that many patients lie, about their hypertension medicine or whatever. If they have to choose between food and medicine…. I think food may come first.

The San Antonio program has a behavioral health person embedded in their clinic (like a diamond) and if a PTSD screen is positive, the doctor or provider can walk them over and introduce them and get them set up. This is more likely to get the person to follow up, because there is still stigma and confusion for ALL mental health diagnoses and people often won’t call the counselor or psychologist or god forbid, psychiatrist.

They have a protocol for a short term four week treatment. Four weeks? You can’t treat PTSD in four weeks! Well, sometimes you can. But if you are making no progress, the person is referred on if they will go. I have the handouts. I do not have an embedded behavioral health person. I wish I did. I am thinking of setting a trap for one or luring them in to my clinic somehow, or asking if the AAFP would have one as a door prize next year, but…. meanwhile, I may do a trial of DIY. No! you say, you are not a shrink! Well, half of family medicine is actually sneaky behavioral health and I have the advantage of being set up to have more time with patients. Time being key. Also I have seven years of work with the telemedicine and access to that psychiatrist. Invaluable.

So what is the most common cause of civilian PTSD? Motor vehicle accidents. I didn’t know that. I would have said assault/rape. But no, it’s MVAs. Assault and rape are up there though, with a much higher PTSD rate if it is someone the victim knows or thought loved them. Rates in the US general population is currently listed at 1%, but at 12% of patients in primary care clinics. What? One in ten? Yes, because they show up with all sorts of chronic physical symptoms.

Re the military, it’s about the same. BUT noncombatant is 5%. High intensity combat has a PTSD risk of 25%, which is huge. One in four. Not a happy thing. In 2004 less then half the military personnel who needed care received it. PTSD needs to be destigmatized, prevented, treated compassionately and cured.

The risk of suicidality: 20% of PTSD people per year attempt. One in five.

Men tend to have more aggressiveness, women more depression.

Back to that PCLC. A score of over 33 is positive, over 55 is severe. There is sub threshold PTSD and it does carry a suicide risk as well. In treatment, a score drop of 10 is great, 5-10 is good and under 5, augment the treatment. Remember, the PCLC is a screening tool, not a diagnosis. I often ask people to fill out the PCLC, the GAD7 and the PHQ9 to see which is highest, to help guide me with medicines or therapy. If I need a formal diagnostic label, off to psychiatry or one of my PhD psychologists or neuropsych testing. Meanwhile, I am happy to use an adjustment disorder label if I need a label. If the patient is a veteran and says he or she has PTSD, ok, will use that.

Untreated PTSD, the rate of remission is one third at a year, the average remission is 64 months.

Treated PTSD, the rate of remission is one half at a year, and the average duration is 36 months. So treatment is not perfect by any means.

Pharmacology: FDA approved medicines include paroxetine and fluoxetine, and both venlafaxine and one other SSRI help.

Benzodiazepines make it worse! Do not use them! They work at the same receptor as alcohol, remember? So alcohol makes it worse too. There is no evidence for marijuana, but marijuana increases anxiety disorders: so no, we think it’s a bad idea. Those evil sleep medicines, for “short term use” (2 weeks and 6 weeks), ambien and sonata, they are related to benzos so I would extrapolate to them, don’t use them, bad.

Prazosin helps with sleep for some people. It lowers blood pressure and helps with enlarged prostates, so the sleep thing is off label and don’t stop it suddenly or the person could get rebound hypertension (risk for stroke and heart attack). I have a Vietnam veteran who says he has not slept so well since before Vietnam.

Part of the treatment for the PTSD folks at the U. of Texas Medical Center is again, destigmatization, normalization, education, awareness and treatment tools.

Hooray for hope for PTSD and for more tools to work with to help people!

fab four

This is for the Daily Prompt: recreate. The American Academy of Family Physicians had a celebration last night at the end of the conference and included a painter who recreated this familiar faces right in front of a large audience. Then it was auctioned off to the highest bidder to fund raise for Houston hurricane victims. Bravo!

 

disaster and withdrawal

When I watch the disaster news, what I think about is withdrawal.

Everyone who is on a substance that causes dependence or addiction is withdrawing.

They don’t seem to ever discuss that, but think…. if you are in Houston or Florida when everything floods, are your cigarettes dry? I don’t think so. And put multiple people in close contact in a shelter, with many withdrawing… I am not surprised that tempers flare.

Let’s look at numbers.

Tobacco: in 2013, 21.3% of the US population age 12 and older, smokes tobacco. Disasters are a reason to quit. It’s hard enough to quit tobacco, but imagine going cold turkey if we have our Pacific Northwest really massive earthquake. Quit smoking now, don’t wait for a disaster. And think about being in a stadium with one in five of the people over age 12 withdrawing from tobacco. Is that fun?

Alcohol: “In 2013, 30.2 percent of men and 16.0 percent of women 12 and older reported binge drinking in the past month. And 9.5 percent of men and 3.3 percent of women reported heavy alcohol use.” Ok, that’s rather vague. If you have a drink or two after work every day or with dinner, will you notice the lack? Yes, I think so, but maybe only 10% of the adults are really going into alcohol withdrawal. That’s a conservative estimate. 30% are probably grumpy.

Illicit drugs: 4-8% of the 40-70 year olds used something in the past month. Are they addicted? Well, some are. And the 18-15 year olds are the most active, around 20%. Methamphetamines, cocaine, crack, crank, heroin, eeee-yuk.

Prescription drugs: “More than half of new illicit drug users begin with marijuana. Next most common are prescription pain relievers, followed by inhalants (which is most common among younger teens).” So let’s see, what percentage of the population is on prescribed opioids, benzodiazepines and barbituates? Ooooo, 1/3 of the US population has been prescribed opioids (2). Chronic opioids are prescribed to 3-4% of the US population, but of course, that is the prescribed chronic pain ones, not the illicit ones. Now, those can have a withdrawal. Alcohol and benzodiazepine withdrawal are the most dangerous for the patient, but in opioid withdrawal the pain receptors go absolutely crazy, like a volcano blowing up. And the tweakers withdrawing from methamphetamines. The sleep medicines like sonata and ambien avoid the issue of whether they are addictive by saying they are for “short term use” — 6 weeks for the former and 2 weeks for the latter, but some people have been on them for years. And marijuana daily, I have seen great difficulty with anxiety and sleep when people are trying to quit.

Marijuana: 7.5% of the population over age 12. How many of those are addicted? I see varying numbers, ranging from 10% to 50%. If you use marijuana regularly, check. Stop it for a week. See if there is a problem. I’d try it before a disaster, because it would add to the stress during….

Caffeine: Ok, I would withdraw from caffeine. 90% of US people are addicted to caffeine. I get a massive headache for 24 hours and then I am ok. I have gone off it more than once….

With ADHD medicines for children, a “drug holiday” is sometimes recommended. If you are regularly using any potentially addictive substance, try a “drug holiday” of your own.

And I think it’s the best motivator ever to quit smoking. Friday I had a couple of dedicated smokers and when I talked about flooded cigarretes, they blanched. Quit now, before you quit in circumstances…

And prayers for everyone in the disaster areas.

1. https://www.drugabuse.gov/publications/drugfacts/nationwide-trends
2. https://www.cbsnews.com/news/more-than-one-third-americans-prescribed-opioids-in-2015/
3. https://www.cnbc.com/2016/04/27/americans-consume-almost-all-of-the-global-opioid-supply.html  Hey, 80% of the world opioid supply is eaten by the US population! Why are US citizens in so much pain? Or are we under the impression that we shouldn’t have to feel pain and by gosh, we can afford the drugs….
4. http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies.

So WHY doesn’t the news talk about this? Because the cigarette and alcohol and prescription drug companies would yank the advertising?

primary care medicine: schedule

I see patients from 8:30 or 8:00 am until 2:00 pm.

We have people say, “You are off after 2:00.”

Well, no. Most days I work for 2-3 hours beyond the patient contact time. Sometimes I come in early and sometimes it is from 2pm to 5pm and sometimes it is the weekend or into the evening.

So what am I doing?

  1. returning phone calls
  2. doing refills. To do a refill I check when the patient was last seen and whether they are due for laboratory.
  3. reading specialist notes and updating medicine lists, diagnoses and contacting patients to get tests or follow up that the specialist has recommended
  4. reviewing lab results and sending a letter or signing to be scanned and to be available at the follow up visit or calling the patient
  5. reading emergency room notes and hospital discharge summaries and setting those patients up for follow up, updating medicine lists and adding to diagnosis lists.
  6. dealing with multiple stupid letters from insurance companies questioning the medication that I have prescribed. Mostly I mail these to patients.
  7. running my small business: long term planning, short term planning, advertising, commercial insurance
  8. 50 hours of continuing medical education yearly
  9.  Updating my medical license, medical specialty board eligibility, business license, CAQH, DEA number, Clia lab waiver, medicare’s shifting rules, medicaid’s shifting rules, tricare’s rules, and 1300 insurance company’s shifting rules and medicine rejections and prior authorizations even for a medicine a person has been on for 20 years.
  10. Worrying about small business costs as reimbursement costs drop: health insurance. Retirement. L&I. Employees. Malpractice insurance, small business insurance, the lease, staff costs.
  11.  Discussing and updating medical supplies and equipment, office supplies and equipment
  12. Updating clinic policies and paperwork per the change in laws. Have you read the Obamacare Law? Over 3000 pages. HIPAA. The DEA. Recommendations from the CDC, federal laws, state laws, internet security, patient financial and social security security.
  13. Trying to track what we collect. That is, say I bill $200.00. Since I accept insurance, the insurer will tell me what is the “allowed” amount per me contracting as a “preferred” provider. The “allowed” amount is really the contracted amount. Then the insurance company either pays it or says that the patient has a deductible. This could be $150 per year or $5000.00 per year. With medicare I then have to bill a secondary if the person has it and then anything left is billed to the patient. Oh, don’t forget copays, if they don’t pay that we have to bill it. So to get paid the complete contracted amount, aka “allowed” we may have to submit bills to two or even three insurances and the patient. We might be done two months after the patient is seen.
  14. Trying to convince recalcitrant computers and printers and equipment that indeed, it doesn’t have a virus, oh, or maybe it does, and fixing them.

My goals are to give excellent care AND to work 40 hours a week. Half of my patients are over 65 and many are complicated, with multiple chronic illnesses.  When I saw patients 4 days a week for 8 hours, with an hour hospital clinic meeting every day, I also spent at least an additional 8 hours and more trying to keep up with most of those things above. The average family practice physician makes more money than I do. But they also report working 60-70 hours a week on average. I do not think this is good for patients or doctors or doctors’ families or their spouses or children. The primary care burn out report rose from 40% to 50% of the doctors surveyed.

We need change, we need it now, and we need to be realistic about how much work is healthy.

When I was still delivering babies, women would ask if I could guarantee doing the delivery. I would explain: “We do call for up to 72 hours. If you go into labor at the end of that, you would rather have a physician who is awake and rested and has good judgement. Besides, I’m a bit grumpy after 72 hours. ” And they agreed that they really don’t want an exhausted burned out physician.

I took the photograph of Mordechai, our skeleton, today. She is genuine plastic. I wish she would do some of the paperwork, but at least she lightens things by making us laugh. She gets various wigs and outfits and sometimes comes out to show a patient a hip joint.

I am NOT attracted to paperwork. I think I am repelled. For the Daily Prompt: magnetic.

 

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/

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.