Category Archives: rural medicine

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The Cult of the Collective Unconscious

My motto is “We are the fever dreams of the collective unconscious”.

I often write things, especially poems, that seem to come from my unconscious. I sit and look at it and wish that I felt what the poem says I feel. Forgiveness, for example.

In my first year of medical school, I started falling asleep. We were in the same auditorium for up to eight hours a day, five days a week. Thank the Beloved for laboratory but sometimes there was nothing to dissect or stare at while I fell asleep against the microscope. Sometimes it was a fifty minute lecturer, talking fast as hell, slides so it was dark, windows only in the black and the shades never raised once all year. There was peer pressure not to ask questions, as then the lecturer would go over fifty minutes. The floor was tilted, so if we heard the clink of a can falling over, we automatically jerked our back packs off the floor, because a tide of some nasty soda would roll down. Or coffee. This was in the dark ages when energy drinks had not been invented.

We went to the bathroom in herds during the ten minute breaks. We sat in the same seats, mostly, through the year. The second year we moved up one floor and sat in the same seats. The whole thing resembled everything I’d read about cults. “I’m joining a cult.” I thought. “This is brain washing, just like cults do.” Since I was raised suspicious, I watched for signs of cultdom all through it. I had gone to college a year late, because of my exchange student year, and I had worked for five years before going to medical school. i had worked at seven jobs by then, the most recent being two years as a laboratory technician at the National Institutes of Health in the National Cancer Institute under Steve Rosenberg, MD. He had camera crews following him around and coming in to the lab. The NIH Building Ten  was a weird place. We had mice and rats on the North/South halls and human patients on the East/West. Try it in the mice and move on to the humans. It was continually overcrowded and the doctoral fellows fought with the medical fellows over inches of laboratory space. The hematology/oncology fellows usually won. When they showed me around the “old” hospital at the Medical College of Virginia, it did not look old compared to NIH, which was always undergoing construction. Most of the time NIH had warnings not to drink the water, because some lab was being torn down and revamped. The Medical College of Virginia looked pretty cush to me.

I started falling asleep in the medical cult lectures. I would fall asleep at 40 minutes in to the lecture. My copious notes, which I mostly didn’t reread, would trail down the page. I drank coffee at every break. I tried standing against the wall, fell asleep, and woke up sliding down sideways. My stomach hurt. I thought that falling asleep standing up in a lecture would be a stupid way to break my arm, so I said, fuck it. I’ll just go to sleep. I quit the coffee and quit caffeine, except for chocolate. My stomach felt better.

And I went to sleep for ten minutes in every lecture for most of the two years.

When we are asleep, the Jungians think our unconscious is connected to the conscious. Actually they talk about the collective unconscious, that is, that the unconscious is all one….  I access yours when I am asleep. Heh, heh. Now, don’t get all paranoid.

So this falling asleep ought to make me an awful doctor. I missed 1/5 of every lecture….   or maybe I didn’t. Maybe 1/5 of every lecture is in the collective unconscious and maybe I can access that. When I write the mystery order that I don’t write an explanation for and the next day it has solved the medical mystery, that might be my unconscious. And yours. And everyones’. What a delightful idea and what a useful talent. I can’t reach the infectious disease physician at UW, so let’s see, switch brain over to unconscious, it can access the infectious disease doctor and his colleagues anywhere on the planet, and write those orders. When my conscious brain objects, tell it to shut up, it won’t hurt the patient, just don’t worry your pretty little head over it…….

And then the multiple doctors who have been telling me that I “should not be taking care of myself” during my recent illness look a bit silly, don’t they? I told the last one that said that, “I’ve contacted eighteen doctors in the last 3 weeks and only two offered appointments and I’m scheduled August 5th, so I think I’ve tried damn hard to find someone to help. If no one will help, then I damn sure will take care of myself.” He was a little shashmushed, as my grandmother would say. I’m sure it’s misspelled, but it’s a Turkish word meaning sheepish and embarrassed and “I’ll shut up and think about that now.” A useful word.

I think it would be very helpful for humanity to learn to access the collective unconscious. How could we fight wars if we could access how the other person thinks and feels and they are us and we are them and we are all one? I think it is a good idea. There, I’m starting my own damn cult. And it is going to be really fun, so you should jump on the bandwagon now, come one, come all, no one excluded, no one discriminated against. The cult of the collective unconscious. Join it. Now.

this essay was rejected by JAMA though I can’t imagine why……

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Fraud in medicine: oxygen

My father died of emphysema in June of 2013. I found him dead on the floor of his house. I expected this because he was nearly a hermit, but it was still hard.

He was on oxygen. It was prescribed to be continuous.

I started cleaning up the house and trying to find his will. I lined up oxygen tanks and called the oxygen company. There were ten tanks.

The oxygen company picked up the tanks.

I found eight more. I was very busy with a large house, a complicated estate, two years of unpaid taxes, he paid bills on line but had not updated the payments when costs increased……

I hired a local estate sale group. They did an excellent job. The house was sold. I picked up the last few things, including the oxygen tanks.

I called the oxygen company. “Why did my father have 18 oxygen tanks?”

They said, “We delivered them as needed.”

I said, “He didn’t need 18 tanks.”

They said, “They are paid for.”

Oh! Medicare paid for the oxygen. No, not medicare. You and he and I paid for it, because we pay taxes to medicare and medicare pays the oxygen company. Well, 80% and then my father paid the other 20% unless he had a medicare secondary insurance, which he also pays for…. Oh, are you under 65 and thought medicare paid for everything once you got it? Sorry to disillusion you…..My father  was supposed to be on oxygen continuously. So the company kept delivering it at the intervals covered by medicare, even though he was not using it all. He sometimes didn’t wear his oxygen and he also had bought his own oxygen concentrator, smaller and easier to move than the one from the oxygen company.

I was furious. “So you kept delivering oxygen even though it was not all being used. And kept charging.”

They said, “We delivered it when it was needed.”

Liars. They delivered more than was needed and I gave some back to them, after medicare had already paid for it.

I still have 8 tanks of oxygen. After all, it’s paid for by medicare, by my taxes and by your taxes. The oxygen is paid for. The tanks belong to the company. I’ll return them when they are empty….. I don’t think the corporation should be able to charge medicare for it twice…..

I should check to see if the company reimbursed medicare and my father for the oxygen when it was returned. If not, I can check into filing a fraud complaint with medicare against the company. But even if they reimbursed medicare and my father’s estate, I am still angry that they kept delivering it when they knew darn well that he had tanks already. Or maybe they don’t even keep track of how many tanks they’ve given out. It’s all about money.

Fight back against corporate greed and fraud. Ask questions. Do not give the oxygen back if it’s been paid for….. give it to someone who needs it instead.

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Eat food not pills

As a United States board certified, board eligible rural Family Physician, I am continually mystified by many of my patients preferring pills to food.

I don’t get it.

Today I will discuss probiotics. I have tons of patients taking probiotic pills. I ask all patients to bring in all pills, prescribed or not, fda approved or “natural”, when they come for their first visit. Many people arrive with a shopping bag. People say, “I am not on any medicines.” Then they pull seven “herbal” medicines out of the bag. A pill is a pill to me. I have never seen one growing on a tree. It’s as natural as a shoe, in my opinion. Shoes don’t grow on my feet, but sometimes I wear them. I feel the same about pills.

I hold up the probiotic bottle. “How long have you been taking this?” I ask.

“For a year,” says my patient.

I then get this internal vision. The probiotic leader in my patient’s stomach speaks, “Another load of refugees. I just don’t know where we’ll put them. Everyone is starving as it is. And dehydrated and dessicated with many dead again. Call the burial team and the grief counselors. I swear, it’s like clockwork. We had a forty eight hour break last Saturday, remember? But then we had to handle all that alcohol….”

“Have you thought of stopping it?” I ask.

“Probiotics are good for the digestion,” says my patient.

“Ok,” I say and try to gently introduce the idea of as few pills as possible. Also if they are taking four preparations with vitamin A, I total it up and ask them to consider lowering their dose a bit……

Why don’t people eat their probiotics as food? I am not talking about the expensive advertised yogurt. Live culture yogurt has always had probiotics, but now they’ve standardized, advertised and raised the price. All of the pickled things are sources of probiotics: Kimchi, dill pickles, sauerkraut and all of those interesting pickles that one gets with sushi. I am not so sure about the sweetened pickles, though my mother used to make watermelon rind pickles in a crock, and I am sure there were very many interesting organisms in them. Delicious, too. A friend said that he first got interested in fungi perusing leftovers in my parents’ refrigerator, and he ended up with a PhD. My digestion has been really really healthy, though my recent strep A was hard on it.

I got live kimchi at the Farmer’s Market recently, and hard cider. Both contain love, I mean live cultures. If you make your own beer, that has live cultures when it’s brewing.

The best thing you can do for your intestinal health is stop. eating. sugar. Quit all the junk food and anything with sugar or corn syrup and make your own food. I have some really dark chocolate or two table spoons of really good ice cream most days. I did eat one donut in the last five months. Perfection is silly, boring and stifling.

Another overlooked cheap source of probiotics that anyone can find: dirt. Yes. Dirt from your yard. It contains all manner of live microscopic things and you are focusing on local bacteria. Don’t wash that carrot quite so carefully and you will be adding to the probiotic culture in your body. If you are in a CSA (community supported agriculture) and get a box from a local farmer once a week, you are getting local probiotics. Do be sure to get your tetnus vaccine updated every ten years, too.

Lastly, think about your food. Would you rather have local probiotics from a local farm or attempt to wash the pesticides off of vegetables that have had pesticide genes added to their genome?

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Taking care of Ebola is hard

“We may never know exactly how [transmission] happened, but the bottom line is that the guidelines didn’t work for that hospital,” said Frieden. “Dallas shows that taking care of Ebola is hard.”

From the Huffington Post: http://www.huffingtonpost.com/2014/10/20/ebola-hospitals-us_n_6018372.html

And for me, a lowly rural Family Practice physician, from the American Academy of Family Practice: “The first steps in preparing your office for a possible Ebola case are to make sure you have all referral contact information ready to go and that you educate each staff member on his or her role should a case present.”

There is only me and a receptionist. We don’t have hazmat suits. Actually I’ve been off sick, lung and vocal cord problems, for all of October.

We have masks, gloves, I do have a white coat that I almost never wear.

Also from the AAFP:”Appointment clerks and front-desk personnel taking calls for appointments should inquire about African travel history in patients calling for appointments for fever, headache, weakness, diarrhea, vomiting, muscle aches or bleeding,” said Mahoney. “Anyone with a positive travel history should be contacted by a provider to gather additional history and determine if public health authorities need to be involved before a patient even presents to the physician office.”

http://www.aafp.org/news/health-of-the-public/20141017eboladisprep.html

We are both going to get our influenza shots this week. Please get your influenza shot. There is a lot more influenza around than risk of ebola in the United States, and influenza kills many many people every year. And even if you “never get colds” and “have a strong immune system”, you might get a mild case of influenza and pass it on to someone who then dies of it. If you tell me “I got flu the last time I got the shot”, excuse me, but that is hooey. First of all, it takes two weeks for your immune system to respond to the shot, so if you got symptoms the next day it could be influenza but not from the shot. Maybe from being exposed to someone with influenza at the grocery store or your doctor’s office. Secondly, people say “flu” and often they mean stomach flu. Stomach flu is not influenza. Third, influenza changes all the time, so about 80% of the vaccinated people are protected most years. That’s right: two weeks after my influenza shot, I am about 80% protected. Not 100%.

Why are we getting vaccinated? For one thing, we are health care workers and we get exposed. And for another, the initial symptoms of influenza are the same as the initial symptoms of ebola. Actually the United States is really rather lucky that the ebola case happened before influenza really hit, because they look too much the same initially. Suppose that three of the quarentined people had come down with influenza….. confusion and panic initially.

So please get your influenza vaccine, because you not only help to protect yourself, but protect others and prevent panic.

Blessings!

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Don’t panic, prepare

We need to help people with ebola in other countries: or else we won’t deserve and won’t get help when the United States is the center of an epidemic.

I am a member of a doctor website called Sermo. I rarely write there, especially after I found advertisements to medical equipment and drug companies saying that they could pay to put announcements and articles on the site and “reach doctors”. Also, apparently some doctors on the site think that it is “safe” to write things. Ha. It’s the internet, silly, the opposite of safe. Your words could get back to your patient, ok?

Anyhow, there was a survey and 75% of the doctors on the site who took the survey (I didn’t)  said we should stop flights from Liberia. I think they are wrong, are not compassionate, and I would cross them off my referral list as discriminatory “I’ve got mine, everyone else can go to hell.” selfish gits. I disagreed and said that the United States could be the center of an epidemic, easily. Could be. Will, some day. We need to treat our international neighbors as we want to be treated.

That being said, I am pleased to see the CDC and United States hospitals now stepping up and getting their hazmat suits on. The rest of us need to NOT PANIC.

If you want to do something, think about your communities emergency preparedness. Are you prepared?

1. Do you have a weeks worth of food, water, medicines, supplies? Do you update the supplies (ok, I have food from 2009. Time to update.)

2.Do you have a weather radio? (http://www.emd.wa.gov/publications/pubed/where_to_get_weather_radios.shtml)

3. Do you have a family meeting point? Do you have an out of state person that the family is to call to check in? That everyone knows about?

4. Have you subscribed to emergency notifications? (http://www.emd.wa.gov/publications/pubed/noaa_weather_radio.shtml)

5. Consider buying your community a shelter box. Or teaming with friends to buy one for the community and another for a disaster area. Our Rotary group buys at least one a year for international disaster relief. (http://www.shelterbox.org/   and http://www.shelterboxusa.org/)

6. Do you have skills? Can you set up a tent, cook food, do medical care, start a fire, build shelter? What skills could stand brushing up? Have you taken a first aid class recently? Have you taught your children these skills? Do you have neighbors that would need help? You would want someone to help your grandmother, who lives four states away. Adopt a local elderly person or couple that you would help……

The picture is my daughter and niece in 2009 in a 19 pound canoe that is very tippy. They only tipped it over on purpose. They both have a lot of skills, some learned at cabins in Ontario, Canada. The cabins are one room and could also be described as shacks: but the kids get to use tools, paddle canoes, start fires, sleep in a tent……

My parents taught care of the tent so well that I have a kelty tent that my sister and I set up, took down and used, and it still does not leak. It is more than 40 years old! Aluminum poles, no shock cords and a fly. Excellent.

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Thoughts on the update from ICD 9 to ICD 10 

I would be very interested in a tune for this poem. 

This poem was rejected by JAMA, the Journal of the 
American Medical Association. Of course, the American 
Medical Association writes the codes. I do not look 
forward to going from the present 14,000 diagnosis 
codes to 42,000. I think it's just another way for 
insurance to delay and refuse to pay physicians. I 
think our country now has a business ethic of "screw 
anyone you can" and I don't like it. 

Thoughts on the update from ICD 9 to ICD 10


They say ICD 9
Just isn't so fine
Not enough codes to choose
To keep us fungking confused

They say ICD 9
Just isn't so fine
The rest of the world
Uses ICD 10, word

But they are liar liar liars
Pants on fire fire
Noses as long as telephone wires

They are liar liar liars
Fungk ICD 10
And let me tell you fungk them
Fungk starting over again

ICD 9 is now 34
Oh what a bore
They say it's too old
I'm older and gold

They say engage a team
Establish a plan
Get focused training
Learn that sh-t from the man

They say what does your practice
See and learn just those codes
Fungk ya'll but wise
I see everything that goes

I do family practice
I'm a rural doctor
The point of the codes
Is insurance don't pay, suckers

They say ICD 9
Just isn't so fine
The rest of the world
Uses ICD 10, word

But they are liars liars liars
Pants on fire fire
Noses as long as telephone wires

I know my ICD 9
Forwards and backwards, up and down
I can code pregnant
by four circus clowns

I can code pulmonary
embolus past
I can code gerbil inserted in the a--

ICD 10
is starting again
Code left or right or other
Those sh-ts would fungk your mother

ICD 10 is starting again
Code where it happened
Or insurance won't pay
Fungkers make my day

They say champion the change
I say channel the rage
Take a book from my page
Incinerate the fungking change

Fungk ICD 10
Fungk ICD 10
Fungk ICD 10
Fungk it again.
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Opiate overuse: a change in diagnostic criteria

In the DSM IV, that is, the Diagnostic and Statistical Manual of Mental Disorders, opioid dependence disorder and opioid addiction disorder are separate. Everyone on a chronic pain medicine for a length of time was expected to be dependent, but not addicted. Addiction was considered rare and was thought to be mostly people who abused opiates. Who took them for pleasure. Oxycontin, heroin, vicodon. Those bad people who were partying. Got what they deserved, didn’t they?

That has changed. My feeling was that it’s been a long time coming, but no one asked me.

In the DSM V, opioid dependence and opioid addiction have been combined into “Opioid Use Disorder”. They are no longer considered separate. They are a spectrum. Anyone who is on chronic opioids is on that spectrum. This is a big change. It has not really penetrated the doctors’ consciousness, much less the patients.

It is quite simple to score. There are 11 criteria. They are yes and no questions. Score and add up. The patients are scored mild, moderate or severe.

Here are the criteria:

Opioid Use Disorder requires meeting 2 or more criteria; increasing severity of use disorder with increasing number of criteria met.

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

2. Recurrent substance use in situations in which it is physically hazardous.

3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

4. Tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication of desired effect.
(b) markedly diminished effect with continued use of the same amount of the substance.

5. Withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome or
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

6. The substance is often taken in larger amounts or over a longer period of time than intended.

7. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

8. A great deal of time is spent in activities necessary to obtain the substance, use of the substance or recover from its effects.

9. Important social, occupational, or recreational activities are given up or reduced because of substance use.

10. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

11. Craving or a strong desire to use opioids.

Mild substance use disorder is yes to 2-3 of these.

My chronic pain patients ask, “Why do you treat me like a drug addict?”

The answer now is, “Because you are on a chronic opiate.”

I am starting to use the criteria in clinic. When I get a new chronic pain patient, I give them the list. I let them tell me.

It is hard because they often recognize 3 or 4 or 5 or more things on the list. They say, “So this is saying I’m addicted.”

“I’m afraid so.”

They grieve.

I am posting this because people are dying. The number of people dying from prescription medicine overdoses taken correctly has outstripped illegal drug use deaths, approximately 27,000 unintentional overdose deaths in 2007.

Here: CDC Grand Grand Rounds: Prescription Drug Overdoses – a U. S. Epidemic.

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

The CDC article says: “The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids, and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month.”That is “approximately” 14 million people.

Please tell your friends and those you love about this. Thank you.

first published on everything2 on June 4, 2014.

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Don’t be perfect, ok?

This reminds me of a kid’s book I had, or possibly have. I may still have it. I don’t exactly know where it is. I’m not perfect. Anyhow, the book is about Peter Perfect, who did everything right. The drawings of the other kids being “bad” were fabulous. At the end the secret is revealed: Peter Perfect is a robot, with a large wind up key in the middle of his back.

I got this link from Big Red Carpet Nursing’s blog, about perfectionism being a big risk for suicide. Many thanks!

http://psychcentral.com/news/2014/09/26/perfectionism-linked-to-suicide/75399.html

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In preparation

I wrote this on 9/26/14 in the midst of much frustration and my lungs still hurting three and a half months after I got sick. I am off from taking care of patients, but still have to try to get my business covered and my patients taken care of. I think there is a component of my vocal cords not working because I am told that I am wrong and to shut up so often.

Favorite example is a Seattle Infectious Disease doctor that I called to ask for help with an infection in our town. He said, “You are a rural Family Practice Doctor. Why would I listen to you?”

I said, “I’m a girl too.” and hung up in frustration. That attitude will not win him any referrals from me. On my permanent stupid moron list, along with an amazing number of specialists. They are either respectful or they aren’t.

Currently I am on no alcohol at all, because I have to do a special diet before a 24 hour urine test. Means no caffeine either, ouch, headache.

In preparation

Today I will start drinking
now
even though it’s only 9:40
in the am

I will stretch two beers
through the long hours
as the alcohol
blocks the receptors
and numbs my aching heart
and lungs

and I will stay home alone
today
so that I won’t talk

time
to rest my voice

in preparation
for the next round
of talk

where I am told
in no uncertain terms
to sit down
and to shut up

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Cost comparison of brain MRI

I called Advanced Medical Imaging (AMI) in May 2014 to get a prior authorization for a brain MRI with and without contrast.

This is for a woman under 65 who is having short term memory problems. We are looking for treatable causes of short term memory loss. The blood work is negative. Next is the MRI.

Her MRI is already scheduled at the local hospital where I worked for nine years. It is the only hospital because we are a small county.

The AMI representative suggested that the patient get the MRI in Everett.

“The cost there is $917.00. It would be cheaper. It is only 29 miles away.”

“Yes, but Everett is across the sound. She’d have to drive around or take a ferry. What is the cost in Bremerton?” I asked. “At the radiology providers there?”

“The cost there is $967.00.”

“And where she is scheduled?” My local hospital has a “Rural Hospital” designation. Medicare will pay them more than other hospitals.

“$4585.00.”

I squeaked. “For the same MRI?”

“Yes.”

“Um. You should tell the patient.” Except that, is the patient willing to drive to Bremerton? And is the cost to the patient the same? And do they care?

“Do you want the prior authorization for that site.”

“Can it be changed if I talk to the patient?”

“Yes, she can call us.”

The prior authorizations are now site specific. That is, I’m getting approval for the MRI at a specific place. I have no idea why.* Seems stupid. Seems like just another hoop to remember to jump through and if we get it wrong the insurance can say, “Oh, ha, ha, ha, we don’t have to pay for that. You do.” Chalk up some more profit for the investors. Mission accomplished, money made.

I called the woman and explained. She was willing to go to Bremerton and said that she would call AMI. I asked her to call us back if she had any trouble.

The cost really matters to my medicare patients and any patient that has to pay a percentage of the cost. If they only have medicare part B, with no secondary, they pay 20% of the bill. 20% of 4500.00 is a lot more than 20% of $900. But some of my frailest most elderly most confused don’t really have a choice. Going 29 miles might as well be going to the moon.

And this is a woman with memory loss, remember? She wrote down the instructions and repeated them back to me three times.

Every phone call to insurance is like this, and makes me wonder about our culture.

* Actually, the authorizations are site specific because some places are “out of network” and the insurance won’t cover anything done there. Though I think the whole point of health insurance in the US is to try to remove money from people and avoid paying for care.

This was first posted at everything2 on Friday May 9, 2014. The woman died last month.