Category Archives: rural medicine

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Adverse Childhood Experiences 4: Psychophysiological Illness

I went to the 46th Annual OHSU Primary Care Review, held at the Sentinel Hotel in Portland, Oregon last week.

It was excellent. It was surreal since the Sentinel Hotel started as a 1923 Elks’ Club and the satyr cupid friezes kept distracting me with the marble penises and war chariots during the lecture updating us on urinary incontinence.

Three lectures that I went to talked about Adverse Childhood Experiences.

This is the first conference that I’ve been to that anyone has talked about that study since I heard about it, in about 2005. I have not been to a lot of big conferences over the last few years because I opened my own clinic and money was tight.

Anyhow, the study is creeping into consciousness.

In the mornings, we had the big lectures in a large hall. There were three break out sessions in the afternoon, held in the main meeting, billiard room, club room and library. We all joked about Colonel Mustard and candlesticks.

A gastroenterologist, Dr. David Clarke, gave a two hour session titled “Hidden Stresses and Unexplained Symptoms II”.

Objectives:
1. How to uncover the cause of an illness when diagnostic tests are normal.
2. How to find hidden psychosocial stresses that are responsible for physical symptoms.
3. The process used to achieve successful outcomes in stress-related illness.

He talked about childhood stress. That if someone had a really difficult childhood:
“Surviving a dysfunction home is a heroic act and produces individuals who are:
a. reliable and get things done
b. detail-oriented
c. Perfectionist
d. Hard-working
e. Compassionate”

So what is the down side? “Surviving a dysfunctional home also produces emotional consequences that may lead to :
a. Long-term relationships with partners who treat you poorly.
b. Addictions to nicotine, Alcohol, Drugs, Food, Sex, Gambling, Work, Shopping, Exercise.
c. Quick Temper or being violence prone
d. Anorexia and/or bulimia
e. Mental health problems such as nervous breakdown or suicide attempts
f. Sacrificing your own needs to help others
g. Self-mutilation
h. Learning not to express or feel your emotions.”

Got that? Right. Not everyone, not all the time, but the adverse childhood experiences add up. These reliable individuals may eventually get enough positive feedback to decide that they deserve a relationship that is actually good. They may get angry about their childhood or past bad treatment. “They may have a really hard time expressing that anger because they spent years learning how to suppress emotion and the feelings may be directed at people for whom there is still some caring. When there is enough of this anger present it can cause physical symptoms that can be mild or severe or anywhere in between.”

Let me give two examples from my own practice. I can’t remember their names or the details, so I am making those up: no hipaa violation.

The first was an elderly woman who came in with her husband for stomach pain. We started with a careful history. We tested for helicobacter pylori. We tried ranitidine. We tried omeprazole. We studied her diet and did an ultrasound to rule out gallbladder disease.

At the third visit I was starting to talk about an upper endoscopy. This was more than 15 years ago, back when we did not start with a CT scan. Her husband said, “Doctor, is there anything else it could be?”

I was surprised. “Well, yes. Depression is on the diagnosis list. Sometimes depression can present as stomach pain. Could you be depressed?”

My elderly lady covered her face with her hands, started crying and said, “I try not to be!” while her husband nodded.

We cancelled the endoscopy. I said it really was not something to be ashamed of and we talked about therapy. She did not want talk therapy and we tried paxil. She came back in two weeks, and already she and her husband were brighter and relieved.

Second case: again, stomach pain, this time in a four year old. Mom brought her in.

I did a history and did a gentle exam. The exam was normal. Her stomach was not hurting now. She wouldn’t say anything.

We established that the stomach pain occurred on week days only, not on the weekend. In fact, usually at the after school daycare, not in school.

“Is there a time at the school daycare that she has stomach pain?” Mom was shaking her head when big sister piped up.

“It happens before recess.” Mom and I turned to stare at the six year old.

I said, “What happens at recess?”

“The big kids knock her down,” said big sister, pissed. “I try to stop them, but they are bigger than me. She’s scared. The teachers don’t see.”

“Oh. Thank you for telling us!” Little sister was crying and mom hugged her and big sister. Mom did not need instruction at that point. She called me a few days later. She talked to the daycare, they watched and the four year old was protected. Her stomach stopped hurting.

Dr. Clarke also described a case, where driving through a town would trigger four days of nausea and vomiting that required hospitalization. This had been going on for 15 years. He figured out why that particular town was a trigger: when the patient recognized the why, he was able to go for therapy.

People aren’t lying about these illness, they are not making them up. Doctors have called it somatization, but really it is the body holding the emotions until the person is safe enough to deal with them. Doctors need to learn how to recognize this and help with respect instead of stigmatization and dismissal.

I hope that more doctors learn soon…

Dr. Clarke’s list for further reading is below. I don’t have any of these yet, but they are on my wish list.

They can’t find anything wrong!, by David Clarke, MD. See also www.stressillness.com

Psychophysiologic Disorders Association: www.ppdassociation.org

Caring for Patients, Alan Barbour, MD

Unlearn Your Pain, Howard Schubiner, MD

Pathways to Pain Relief, Frances Anderson PhD and Eric Sherman PhD

Ted talk about ACE scores: http://www.acesconnection.com/blog/nadine-burke-harris-how-childhood-trauma-affects-health-across-a-lifetime-16-min

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Angel Witness

Sometimes
Even as you make
The same mistake
Cross the threshold
Open the door
Lift the glass

You feel the presence
Of angels
Drawn by the seriousness
Of your decision

Present
Not to pull you away
From the cup
The drug
The wrong man
The dire pattern
You feel their intensity
The presence
As if outer space
Has clung to their wings
Or motes from heaven
Alien
The weight of their gaze
And their interest

Sometimes
Even as you make
The same mistake
It’s not the same
To sense an angel
Witness

previously published on an obscure writing site

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Those Elks…

The photo shows part of the ceiling decoration in the Sentinel Hotel in Portland, OR, which was built in 1923 as an Elks’ Club. I have some questions about those Elks…..

This week I was in Portland, Oregon for a Primary Care Review put on by Oregon Health Sciences University. The conference was held in the Sentinel Hotel. It has high beautiful decorated ceilings and walls. In the afternoon there are break out sessions, which are held in the Library or the Billiard Room. We need a candlestick, a wrench and Colonel Mustard. It is a little bit surreal to be in this gorgeous setting and then hear lectures about complications of diabetes and the United States obeisity epidemic.

Our last breakout a few days ago was two hours about addiction medicine, held in the Library. The photo is of the frieze just below the ceiling. There are cupid satyrs with weapons and horses. Some are nude and they are definitely male. They are not engaging in activities like the brothel wall paintings in Pompeii, but it does make me wonder about those Elk members in 1923.

I asked a person at the front desk about the building and she said that it was only an Elk’s club for a few years, because of the depression. I asked what else it had been used for and she looked rather severe and said, “other things”. There are naked women and cupids around the frieze in the lobby: I will try to get a decent picture of them, too.

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Bill Cosby and the Real Men

I do not want to decide if Bill Cosby is guilty. I am not on a jury nor am I his judge. But I do have a question: Where are the men?

Women have come forward. Woman after woman. They were younger than him and he was already famous and on his way. But there were men there too, who worked with him. Why haven’t we heard from them? We have heard from only one man.

Various people say how dare these women come forward after all this time. But back then, I think that if a woman had gone to the police, the attitude may well have been, “You were out with a married man. You can’t prove anything, you slut whore.”

Why do I say this? In my second year of medical school, in 1990, we had a lecture about domestic violence and rape. A day or two later, I was with four people from my class: we were two men and three women.

One of the men said, “If I were a woman who was raped, I would never tell anyone.”

I said, “Oh, I’d be in the emergency room getting a rape kit done for evidence and I’d have his ass in jail immediately.”

Silence. Then he said, “Um. Wow. Can I ask why?”

I explained that I had been sexually abused by a neighbor at seven. Being a bit clueless, I asked my mother about what it meant when a guy rubbed his penis on a girl. She explained sex. I got worried that I was pregnant, I was sure that I was no longer a virgin and I thought it was my fault. And I told my four year old sister never ever to go near him. I think my mother had no idea what was in my head. I had a doctor appointment a few months later and decided that I probably was not pregnant, because surely the doctor would have noticed. I felt guilty and at fault for letting it happen. I was seven. On the school bus to second grade I thought sadly that I was the only girl who was not a virgin.

I was lucky in the I could and did stop it. It was not a family member. I stood up for myself at seven.

I revisited it in college. I heard a program about how rape victims feel and how guilty and at fault they feel. And how they are often treated with suspicion, what were they doing to inflame the man? I was so stunned as they described the feelings that I had at age 7 that I burned the bacon I was cooking.

“So,” I said, “If I walk naked down the street, I am fine with being arrested for indecency. But no one can rape me. That is violence and it is illegal.”

The medical school men continued to look at me. “See?” I said, “I am ok. I think the perception is still that women are “ruined” and destroyed by rape. The numbers of women experiencing rape or domestic violence is one in four.”

“Yes,” said one of the guys, “But I didn’t believe that.”

“Well, we have three women here.” We all looked at the other two. One nodded yes and the other shook her head no.

After the child abuse lecture, the male student came to me. “I thought of you during the lecture. What you said will make me treat women who have been abused differently. Thank you.”

So: where are the men who worked with Cosby? Was this an open secret?

If the women are telling the truth, then the men who worked with Cosby know. I am afraid that the silence means:

They didn’t want to know.
They turned a blind eye.
They tell themselves they can’t prove it.
He was the goose laying the golden egg.
Those girls deserved what they got, he was a married man.

So: Where are the REAL MEN who worked with Bill Cosby? If it is true and they stay silent, they are accomplices. Every single one of them should call their lawyer and say, “I saw evidence that supports what the women are saying. Please contact their lawyers so that I can make a statement.” Or: “I am willing to make a statement that I worked with Bill Cosby for x years and never saw anything suspicious.” Not a statement for the press. A statement that they will stand by in court: that it’s the truth, the whole truth and nothing but the truth.

And think if it had been men being preyed on. Take that as a scenario. Men would have screamed the house down and what’s more they would have been believed. And they would not be accused of leading him on or being whores or being sluts or asked what they were wearing.

Will the Real Men who worked with Bill Cosby please stand up.

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Adverse Childhood Experiences 3: Attachment Disorder

I ought to have an attachment disorder, which now is called “separation anxiety disorder” in the DSM IV, now redefined in the DSM IV-TR and then the DSM V. That is, they keep changing the definition of psychiatric disorders. It’s a bit unnerving, isn’t it? Not only the brain is “plastic” and can be rewired throughout our lives, but the psychiatric diagnosis manual is being updated.

When I went into allopathic medicine, I was under the impression that I needed to learn everything I could and apply it. Spectacularly wrong. I needed to learn everything and then track everything because at least one fourth of what I learned was wrong or was going to change. I just didn’t know WHICH 25% was wrong.

This is why older doctors have a healthy skepticism towards new medicines, new equipment, new ideas. Older doctors are more likely to use old cheap medicines and eschew the new-fangled samples. It’s not just that the pharmaceutical companies only give us samples of the new expensive stuff. It’s also that some of the new expensive stuff is not as good as advertised and has a chance of hurting people. I still would advise my patients to use coumadin (warfarin) if they have a clotting disorder. Yes, you can take the new drugs without doing a monthly blood test — BUT if you bleed, I can’t reverse the new medicines. So I wouldn’t take them: if I need a medicine to keep me from clotting, I want coumadin. I will decide about the new medicines in 5-10 years. Old and cynical, that’s me….

As previously written, I had five “experiences” under age three that left me not trusting adults. However, the adults seemed to love me, even though they kept abandoning me to other adults. At under three, this did not make sense. I could have decided never to trust anyone and presumably would have really gone off into some sociopathic bad place, but I didn’t do that.

The clue to what I did is in my mother’s stories. My sister was born five days before my 3rd birthday. She came home right by my birthday, at Easter.

My mother said, “You asked if you could dress Chris. She was two days old. She was nearly ten pounds and had a triple chin. You wanted to put a lacy dress on her. I decided that you could try and told you to be very gentle.

You put Chris into the newborn baby dress. She was so big that it barely fit and in fact, that was the only time she ever wore it. You had to stuff her arms through the sleeves. She cracked her eyes and looked at you, but she did not object at all. You were gentle.”

That doesn’t seem like much. Next story:

My mother said, “You would meet visitors who came to see Chris at the door. You would say “Come see my baby.” I let you open presents for Chris because she didn’t care. You would show the visitors your sister.”

My baby. That is the key.

I think what happened is this:
1. The adults who took care of me did seem to love me.
2. Even though they loved me, they kept abandoning me, or giving me to other adults. I really really disliked this.
3. I thought that adults were misguided and wrong to give me away. I thought there must be some explanation. I would try to figure it out. Meanwhile, I was going to take care of my sister: she was MY BABY. I was going to show those stupid, loving, confused adults how to take care of a baby and NO ONE was going to give HER away. I could love adults but no way was I going to trust them.

That was my crisis brain wiring by age 3. Adults are loving and untrustworthy. You can love them back but they may abandon you to someone else at any moment. You can’t predict what they will do. They may be even LESS trustworthy if they are loving and you know them, than if it is a stranger.

My mother again, “When I got you back at nine months, you didn’t know me. You wanted to be as independent as possible. You missed your (maternal) grandmother. In the grocery store, you would cry if you saw a white haired woman. We couldn’t comfort you.

I thought that you didn’t like us at all until you ate a cigarette butt and got really sick. You let us take care of you. Then we left you with friends for a night. You were absolutely furious when we got back and I thought that you really did like us….”

Poor young mom, 23 and recovering from tuberculosis and still not strong, with an angry and grieving nine month old who really didn’t want much to do with her and didn’t trust her at all…..

Changes from the DSM IV-TR to the DSM V: http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

The DSM IV criteria for separation anxiety: http://behavenet.com/node/21498

Theme song: The Devil Makes Three “All Hail”

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Branded

This photo is really my brand. In 2009 my rural county hospital dismissed me as a physician because I argued against the daily 18 patient quota that they said that Congress had set us. I said, “I will go argue with Congress.” I was not sure how I would get to Congress or when.

Meanwhile, in Oregon, a group called the Mad as Hell Doctors was readying to hit the road. Two weeks before the Mad as Hell Doctors hit the road to go across the country to give talks about single payer healthcare and to listen to citizens talk about their healthcare experiences, a friend called me.

The friend had gone to the Mad as Hell Doctors’ first program, a practice run in Sequim. It was well attended because the community had a controversy over the word “Hell”. The friend said, “It’s a bunch of older white males. They need a woman. You’re off from work: you should go.”

I researched them and called a friend who is a very experienced agitator. He said, “Do it.” I called them and my father drove me to the Bremerton ferry. I got off the ferry in downtown Seattle and was picked up on a street corner to join the Mad as Hell Doctors. I had never met any of them. That evening I was part of the program.

I was and am mad as hell and often sad, frustrated, appalled and incensed by the healthcare industry in the United States, that leaves people without care and dying in spite of costing each and every one of us twice as much as any other country in the world. And all of the CIVILIZED countries have single payer. Am I saying that the United States is uncivilized? Yes, frankly, I am. We are a country run on greed by corporations currently and I am fighting it.

The Mad as Hell Doctors traveled California in 2010 and I was there for a week of that trip. In 2011 they toured Oregon. We continue to work locally, at the state level and at the national level for single payer healthcare, medicare for all. I think that it will happen and hopefully during my career.

We ended the first trip at Congress and the White House. I sent a postcard to my former employer saying “See? I said I would go to Congress.” We haven’t won the health care battle yet but we will.

Here is a ten minute program that I did in Sequim, WA in (2012) at the American Awakening event:Β  Enjoy. If you want to see WHY we are Mad as Hell, watch “Health, Money and Fear” and the other videos at this site. For more information Physicians for a National Health Care Program is excellent and Health-Care Now! is also excellent.

You can make a difference. Do you know anyone who has lost their house, not gotten care soon enough because they didn’t have insurance or were under insured, or has been harmed or died because they were not able to afford or access care? Gotten sick and lost their job and lost their insurance? You, too, should be Mad as Hell and fight to change this.

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Fraud in Medicine: Pain cream fraud

I got a call at home saying that there is a new topical pain medicine for chronic pain. I pressed the number to talk to the agent. I talked to Shawn. He said he was with “Health Advisors”. He asked if I have had chronic pain for long.
I said “Oh, yes.”
He said, “Can I get your name and number to have one of our associates call you?”
I said, “Can I get your number so that I can call you back? My daughter needs me.”
Shawn: “I will have to call you back.”
Me: “I am not giving you any information. Does your company have a number I can call you back?”
Shawn: “I will have to call you back.”
Me: “No way am I giving you any information.” Hang up.

The phone call started by saying that I could get this great pain cream, my insurance would cover it and I don’t even need a prescription…. I just have to give them some information. Right. How much do we want to bet that there is a little fee to cover shipping and handling and they need my credit card or bank information? DON’T FALL FOR THIS SCAM!

I looked on line for “Health Advisors”. I did find an insurance company. Nothing obvious about a pain medicine cream. I looked for pain medicine creams and found:

http://prescriptionpainreliefcream.com/health-care-professionals/

Live chat representative
My Pain Cream MD Live Chat
Chatting with Ben
Ben: Hello, thanks for contacting My Pain Cream MD. My name is Ben, may I have your name?
Visitor: Are you connected with Health Advisors? I just got a call about a chronic pain cream that my insurance would cover.
Visitor: They wouldn’t give me a number to call, so I thought it might be a scam.
Visitor: What are the active ingredients in your cream?
Ben: One of our representatives can discuss this in greater detail. Before we proceed, may I have your name, phone number and email to better assist you?
Visitor: No, I don’t think so. You have not answered my question. Why would I give you any information?
Visitor: Pass me on to the representative. Or if you require that information first, then I will sign off.
Ben: I am an internet agent representing the company for visitors to their website. I would be happy to pass your contact information on to a representatives who can answer more specific questions and assist you further. Would you like to speak with someone in the office?
Visitor: Are we talking live chat or are you requesting my number? Last chance … live chat and you can’t have my name.
Ben: Unfortunately, that feature is not available. I’m not a representative and am not able to answer your questions. May I have someone from our office contact you? They can assist further.
Visitor: Tell your company to go jump. Information in exchange for email and name and all? Over my dead body. Scammers.

And looking for “Health Advisors” I found:

http://www.futureworldcorp.com/board

Well, how nice. “Mr. Robert Carr for the past forty years has enjoyed tremendous success in law and pharmacy.” Um. This is an attorney, folks. “Rob designed and built the original concept specialty compounding pharmacy, United Prescriptions Services in 2002.”Β  Lovely. How reassuring. Don’t you just want to use a compounded medicine? Comes with free fungus…….

And my family practice medical advice?

TAKE AS FEW PILLS AS POSSIBLE.

EAT FOOD

EXERCISE

QUIT SMOKING, REDUCE ALL ADDICTIVE SUBSTANCES AS MUCH AS POSSIBLE

DO THINGS YOU ENJOY

VALUE GOOD FRIENDS AND GOOD FAMILY

Don’t fall for the “neutraceutical” crap. Hello, it’s food that has been extracted in a lab into pill form. What in the heck is natural about that? I have never seen a pill grow on a tree, though the way things are going….. if they grow a pill on a tree, I personally won’t take it. And you shouldn’t either.

The picture is because these scams, trying to get to people with chronic pain, make me so HOT!